(Emil Pascarelli M.D.) Dr. Pascarelli's Complete G

Dr.
Pascarellis
Complete Guide to
Repetitive Strain
Injury
What You Need to Know about RSI
and Carpal Tunnel Syndrome
Emil Pascarelli, M.D.
John Wiley & Sons, Inc.
Dr. Pascarellis
Complete Guide to
Repetitive Strain
Injury
Dr. Pascarellis
Complete Guide to
Repetitive Strain
Injury
What You Need to Know about RSI
and Carpal Tunnel Syndrome
Emil Pascarelli, M.D.
John Wiley & Sons, Inc.
This book is printed on acid-free paper.

Copyright 2004 by Emil Pascarelli. All rights reserved
Published by John Wiley & Sons, Inc., Hoboken, New Jersey
Published simultaneously in Canada
Design and production by Navta Associates, Inc.
Illustrations credits: pages 11, 12, 13, 14, 16 (top), 49, 61, 79, 152 (both), 154 (top and bottom), and 156 courtesy of Ahmet Sinav, M.D.; pages 16 (bottom) and 24 reprinted with permission from Scientic American Medicine; page 46 reprinted from B. M. Sucher. 1990. Thoracic
outlet syndrome: A myofascial variant. Part I: Pathology and diagnosis. The Journal of American
Osteopathic Association 90 (8): 471479; pages 136 and 142 reprinted with permission from
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Library of Congress Cataloging-in-Publication Data:
Pascarelli, Emil F., date.
Dr. Pascarellis complete guide to repetitive strain injury : what you need to know about
RSI and carpal tunnel syndrome / Emil Pascarelli.
p. cm.
Includes bibliographical references.
ISBN 0471388432 (paper : alk. paper)
1. Overuse injuriesPopular works. 2. Carpal tunnel syndromePopular works. I. Title.
RD97.6.P368 2004
617.1'72dc22
2004002610
Printed in the United States of America
10 9 8 7 6 5 4 3 2 1
To my wife, Dolores Klein Pascarelli, my daughter,

Claudia Pascarelli Lyon, and my son, Eric Pascarelli, without
whom this book could not have been created
It is the familiar that usually eludes us in life.

What is before our nose is what we see last.
Sir William Barrett
Contents
Foreword
xi
Preface
xv
Acknowledgments
Introduction
1. Understanding RSI
xvii
1
9
2. Getting the Diagnosis
27
3. RSI and Your Emotions
69
4. RSI and Your Eyes
77
5. Managing Pain
87
6. Your Lower Back
105
7. Physical and Occupational Therapy

for RSI
111
8. Ergonomics: Making Your Equipment Fit
131
9. Biomechanics: Using Your Body
149
10. At Home with RSI
163
11. Getting Back to Work
171
ix
Contents
12. RSI and Musicians
183
13. Other Causes of RSI
201
14. Beating RSI: A Five-Step Protection Plan
209
Glossary
215
Further Reading
225
Internet Resources
231
General Scientic References on RSI
233
Index
239
Foreword
When Dr. Emil Pascarelli founded the Miller Health Care

Institute for Performing Artists in 1985, he could hardly have
appreciated the pioneering nature of his vision. Nor could he
have realized the profound effect his novel and painstaking
approach would have on the way physicians would come to
view performance and workplace injuries. Under Pascarellis
direction, the Institute at Columbia University in New York
became one of the largest clinics in the country treating repetitive strain injuries. Growing to about a thousand patients a
month, with musicians, dancers, and keyboard workers of all
varieties, an enormous experience was developing. Even after
many previous fruitless consultations and treatments, patients
benefited from the application of a meticulous medical and
ergonomic approach, which was complemented by comprehensive upper body biomechanical assessment, laboratory tests,
and nally routine videotaping of a patients customary activity.
An integrated program of ergonomic modication and a highly
rened treatment program achieved success and rehabilitation
even for the chronically aficted.
Dr. Pascarelli recognized that the workplace had evolved
from the backbreaking and lung-challenging labors of previous
centuries to the unique demands of the modern ofce. Repetitive
xi
xii
Foreword
strain injury (RSI) now makes up more than 60 percent of workrelated illnesses. Dr. Pascarelli recorded subtle differences in the
manner in which workers performed their jobs, and how some
become disabled. He recognized the significant physical
demands on what he termed the sit-down athlete, and how
poor biomechanical work habits or poor ergonomic design can
lead to injury-causing behaviors such as the disabling keyboard
habits of leaners, loungers, and clackers.
Unfortunately, outside of the institute, the approach to
patients with overuse syndromes had evolved in a somewhat
chaotic clinical environment, with each specialty focusing on one
or another familiar characteristic. Often the diagnosis was based
on the most prominent symptom rather than on the recognition
that tendinitis or carpal tunnel syndrome may be part of a larger
constellation of symptoms, the recognition of which would lead
to the real etiology of a patients disability. The poor diagnostic
results derived from the unfortunate erosion of physicians clinical skills, a reliance on limited physical examinations, and moving too quickly to highly focused laboratory tests. In this setting,
equivocal or incomplete test results are often accorded undue
signicance, even in the face of contradictory physical ndings.
These misleading clues often divert ones attentionto the detriment of the patient and the frustration of the clinician when the
expected cure doesnt materialize.
Returning to basics, Dr. Pascarelli, through his highly diligent approach, brought order out of chaos. He emphasized the
fundamental characteristic common to all these injuries: a history of repetitive use of the upper extremities in an intense and
often awkward fashion.
The lessons learned redefined the terms of cumulative
trauma, repetitive strain injury, and overuse syndrome. His
Sherlock Holmes approach, considering every clinical clue
rather than discounting those that do not t a preconceived diagnosis, has rescued many patients from the distressing labyrinth
of multiple diagnoses, failed therapies, and increasingly frustrating consultations. This clinical approach was based on evidence
that despite initial symptoms in the ngers, hands, and arms,
Foreword
xiii
work-related upper-extremity disorders constitute a diffuse neuromuscular illness characterized by signicant upper-body disturbances that affect function in the arms, hands, and ngers.
Once therapy is targeted at the proper neck and shoulder sites,
the symptoms begin to disappear.
Now, in addition to the benets to the many thousands of
patients at the institute, Dr. Pascarelli has given us an invaluable
resource, a welcome distillation of his unique experience, equally
valuable to patients, their families, therapists, and physicians.
This book guides the reader through an otherwise daunting
maze in the company of a skilled and compassionate healer.
There is invaluable advice on managing pain, and a constructive approach to physical and occupational therapy. Careful
analysis of thousands of videotapes of people working and musicians playing has led to accurate data on the ergonomics and
biomechanics of upper extremity and neck and shoulder disorders. Rational decisions can now be made regarding workstation
modications as well as mitigating the rigors of daily living. This
guidance is all the more valuable coming from a physicianinvestigator who has, perhaps more than any other specialist,
walked the walk. Physicians, therapists, and patients reading
this book now have a unique opportunity to look over the
shoulder of one of the foremost RSI specialists as he goes about
his work.
It is always a major benet to the health care community
when an astute clinician-scientist critically evaluates an extensive
and unusually successful practice, and then carefully documents
the lessons learned. This readable book is a gift to us all: workers, patients, therapists, and physicians, as well as all who would
ensure a safe and productive workplace.
Herbert I. Machleder, M.D.
Emeritus Professor of Surgery
University of California, Los Angeles
Preface
Each year we learn more about how to diagnose and manage

repetitive strain injury (RSI), a disorder still poorly understood
by many. With this book, I hope to clear up some of the mystery. My own experience has taught me that RSI is no more difficult to diagnose than many other medical illnesses. The
confusion occurs because it is usually work-related, and caused
by many factors. Yet a good history and complete physical
examination by an interested physician can arrive at the diagnoses necessary for successful treatment.
Posture plays a key role in the genesis of this disorder. Poor
posture can lead to nerve impairment and subsequent soft-tissue
effects on the entire upper body. RSI is realnot a product of
your imaginationand can become a chronic disability if left
untreated. We have also become more sophisticated in the treatment of RSI as we observe people improving with focused physical therapy; home exercises; and ergonomic, biomechanical,
psychological, and medical interventions. This book reects my
personal observations of patients as well as the research work of
many others in the eld. My hope is that better understanding
of this illness will lead the way to recovery for the many persons
aficted with RSI.
xv
Acknowledgments
any people, both directly and by their inuence, have contributed to making this book possible.
Thanks to Lisa Sattler, M.S., P.T., a talented and extraordinarily caring physical therapist and lecturer, for all her help and
advice with the exercise program and other therapies grounded
in her long experience with RSI patients. Vera Wills, professor
of graduate pedagogy at the Manhattan School of Music, an
insightful and skilled ergonomist and educator, made important
contributions to chapters 8 and 12. To Yu-Pin Hsu, M.M., M.S.,
OTR/L, Ed.D., for wearing two hats: accurately notating my
patient exams, which were so important for this book, and contributing elements of her doctoral research. Thanks to Ariel
Stoll, who was extremely helpful in assisting me with my
patients.
I would like to thank medical illustrator Ahmet Sinav, M.D.,
for his ne work in producing many of the illustrations. Dr. Herbert I. Machleder, emeritus professor of surgery at UCLA Medical School, kindly wrote the foreword of this book and in our
many discussions on RSI spurred me on with his enthusiastic
encouragement. Dr. Sidney J. Blair, emeritus professor of orthopedic surgery at Loyola University, was an important source of
xvii
xviii
Acknowledgments
ideas and support. My longtime colleague Martin Cherniack,

M.D., M.P.H., professor of medicine at the University of
Connecticut Health Center and director of the Ergonomics
Technology Center there, was a knowledgeable and inspired
collaborator on patient care.
John J. Kella, Ph.D., was a valuable associate early in my
work on RSI in musicians. I also would like to thank Professor
Tom Armstrong, Ph.D., of the University of Michigan College
of Engineering and director of the Center for Ergonomics there,
and David Rempel, M.D., professor of medicine at the University of California, San Francisco, and director of the Ergonomics
Program there, for the inspiration that their work on RSI provided me. The astute work of Stuart B. Leavitt, Ph.D., on eye
problems was a valuable resource. I also would like to thank the
editors of the Journal of Occupational Rehabilitation and Kluwer
Academic/Plenum Publishers for allowing me to quote some of
my research results. Bruce Hymanson, P.T., the inventor of
Bodyblade, and his wife, Carrie Hymanson, P.T., offered skillful
advice on upper-body treatment methods. Thanks to Perry
Ritter for his talented ergonomic modications of musical instruments, which made it possible for many injured musicians to
continue their careers. Thanks to Hugh McLoone, ergonomist
and usability researcher at Microsoft, for keeping me up to date
on the latest technical innovations in computer equipment.
Thanks to Thomas W. Miller, executive editor, John Wiley
& Sons, for his editorial support and patience in making this
book possible and to Nicholas Bakalar for his skillful editing and
organization of the manuscript. Harvey Klinger, my agent, was a
staunch supporter and communicator of my efforts.
Introduction
Medicine, like law, should make a contribution to the

well-being of workers and see to it that, so far as possible,
they should exercise their callings without harm. So, I for
my part have done what I could and have not thought it
unbecoming to make my way into the lowliest workshops
and study the mysteries of the mechanical arts.
Bernardino Ramazzini, 1713
You may have experienced discomfort or pain in your hands,

wrists, arms, shoulders, or neck. Perhaps you are only sensing
mild discomfort, but are beginning to fear something more serious. If youve noticed that these symptoms appear while youre
doing repetitive work or just after youve stopped doing it, if you
are in discomfort for your entire workday and beyond, you have
reason to be concerned. You may be facing repetitive strain
injury (RSI) in its early stages.
What you need is a guide to understanding RSI and what
you can do about it. Finding the right doctor, the right diagnosis,
and the right treatment requires understanding a complex problem that even most doctors are not trained to handle.
Dr. Pascarellis Complete Guide to Repetitive Strain Injury
If your injury has persisted for some time, you may have
been to one or more specialists. Opinions can differ from specialist to specialist depending on their experience with RSI. You
may have been given medications, wrist splints, neck braces,
and exercises, but if nothing youve tried has had more than a
temporary effect on your pain or other symptoms, you need this
book.
Many of my patients complain that health professionals,
employers, and often fellow employees dont understand what
they are going through. Because RSI has no obvious visible
signs, the implication is that it is all in your mind, youre a
hypochondriac, a slacker, a malingerer. You simply dont want to
get better. Worldwide, people are nding that they have to
defend themselves against these charges, sometimes explicit and
at other times implied, when all they want is to get better and be
themselves again.
A study of fty-two Australian women with RSI whose
work ranged from typing to poultry processing shows that the
problem is universal and far from resolved. These women were
interviewed about their search for help from physicians and
health care providers. The study, which was aptly called Pilgrimage of Pain, quotes one of the women interviewed:
and then people tell you there cant be anything wrong
with you. I said, Look, Ive had ve children. I know pain.
I know how it feels. I know when its gone and I do feel
pain. Dont tell me I dont feel pain because I know pain.
Im not stupid. I know when something hurts and when it
doesnt and I know when I do so much that my arm is
killing me.
RSI has numerous causes, which is one reason for the confusion about the disorder. Because I have experienced RSI as
well as treated it, I know there is hope for you. You are not hysterical, you are not a hypochondriac, and you are not a malingerer. There is effective, conservative treatment that can lead to
healing and freedom from pain. This book will help you nd
the way.
Introduction
RSI is a general term used to describe a disorder in which

people develop symptoms such as pain, numbness, stiffness, and
weakness as a result of sustained repetitive work, often done
under adverse conditions. These can range from ordinary daily
stress to truly bad work setups and work conditions. Usually the
pain or other symptoms affect their work and other normal
activities. RSI is a widespread illness involving soft tissues of the
upper bodynerves, muscles, tendons, ligaments, and blood
vessels.
RSI is treatable conservatively for most people using several
different approaches, often simultaneously. Posture correction
and retraining are often the rst steps. Customized physical
therapy that includes upper body soft tissue work (well get to
this procedure of deep massage later in this book) is often
required. Strengthening and stretching exercises are also useful,
and must be done under supervision. Ergonomic evaluation
the consideration of your work equipment and spaceis important, as is training in biomechanics, the proper use of your body
to accomplish tasks comfortably and safely. Modifying the way
you do things is often necessary, and you can learn to accomplish what you need to do without pain. Finally, both medication and psychological counseling can be useful in controlling
pain and healing tissue.
Rarely, surgical intervention is required, but such procedures have their risks as well. In my view, surgery is useful
under limited circumstances (e.g., carpal tunnel release surgery).
But those patients I have seen after unsuccessful corrective surgeries often become more difcult to treat because of tissue scarring and loss of soft tissue mobility.
RSI by Other Names

Repetitive strain injury is not the only term used to describe
this illness. In the scientic community the terms cumulative
trauma disorders (CTDs) and repetitive motion disorders
are often used. You might be told you have regional arm pain,
occupational overuse syndrome (OOS), cervical brachial pain
syndrome, work-related musculoskeletal disorder (WRMSD),
or upper extremity musculoskeletal disorder (UEMSD). If you
are a musician, overuse syndrome is often used to describe
your problem.
If you are confused, you have a right to be, because the
many terms in use reect the differing and conicting opinions
held by health care professionals.
What Causes RSI?

There are many causes, not all of them obvious. The kind of
work you do is perhaps primary, because repetitive keyboard
use or repetitive manual activity of any other kind can be a
major cause. Long work hours without sufcient breaks and
meeting deadlines under stress are also contributors. Poor lighting, poor ventilation, crowding, and other undesirable work
environmental issues are additional factors. Even the routine
activities of daily lifedriving, housekeeping, cooking, gardening, home repairscan lead to RSI. If youre not sitting or moving correctly, youre damaging yourself repeatedly when youre
at work. If your job forces you to work too fast, or to work on
irregular schedules, you are at risk. Your physical condition also
affects your susceptibility. Poor posture and physical tness,
lack of exercise, decient diet, and irregular sleep patterns can all
be contributory. Stress from family problems, work-related conicts, or nancial affairs can manifest themselves in RSI. Anxiety, depression, fear, and panic also contribute. Sometimes there
is a hereditary predisposition to RSI from height, weight, sex,
age, or double-jointedness or other anomalies. Medical problems
such as diabetes, arthritis, thyroid disease, or hypertension can
all make RSI more severe. Finally, smoking, alcohol, and drug
use, along with all the other problems such habits bring with
them, can also contribute to RSI.
Introduction
What RSI Isnt

There is at least as much confusion about what RSI isnt as
about what it is.
Its not carpal tunnel syndrome. Or at least thats not all it is.
Patients often come to me with a self-diagnosis of carpal
tunnel syndrome, which most people think is their main
problem. Carpal tunnel syndrome (CTS) is one very specic diagnosis, and by no means the major culprit in RSI.
In fact, a study of 485 of my most recent patients shows
that only 8 percent of them actually had carpal tunnel
syndrome. Another study of symptomatic medical secretaries found carpal tunnel syndrome in only 3 percent.
Carpal tunnel syndrome is relatively uncommon in keyboard users, and is more often found in workers in heavy
industry who do repetitive tasks.
Its not regional arm pain. Another commonly used term for
RSI is regional arm pain. Not only does this term imply
that the illness is only where the pain is, it also minimizes
the seriousness of RSI, putting it into the category of general aches and pains. When a physician tells you that you
have regional arm pain, he or she is almost certainly not
doing a complete examination. Correct diagnosis depends
on a complete upper body physical examination.
Its not necessarily a case for the surgeon. RSI is generally not a
condition that requires surgery, although there are
advanced conditions that may have progressed beyond
conservative treatment. I discuss some of these conditions in chapter 2. It is worth saying here that surgery can
often make RSI more difcult to treat conservatively and
that you should investigate a conservative therapeutic
approach, such as those I outline in this book, before you
consider surgery.
RSI is not a mysterious, ill-dened illness. It is not the general aches and pains of growing older. It is not all in the mind.
And it certainly is not a hysterical reaction of bored, lazy, or

underperforming workers. In fact, often the hardest-working
people are its victims.
In a recent survey of 250,000 businesses employing
101,646,500 people, the U.S. Bureau of Labor Statistics found
276,000 reported RSI cases among ofce workers, laborers, and
fabricators. This number didnt include those working at home,
or doing freelance work, or other RSI-affected workers such as
dentists, dental hygienists, surgeons, physical and occupational
therapists, sign language interpreters, artists, and musicians, to
name just a few.
RSI is not the same kind of single-cause occupational illness
as asbestosis or black lung disease, but is considered workrelated because RSI has so many contributing causes.
In my practice, about 60 percent of patients continued their
usual work activity even while in pain. Most of them continued
to work because they had to keep a steady income or were afraid
of losing their jobs. The increasing intensity and chronic nature
of their pain are what ultimately brought people to me for evaluation and treatment. Most came in within a year of the onset of
their symptoms. Prevention and early intervention are arguably
the rst lines of defense for all at-risk workers, but because RSI is
such a complex illness and is so poorly understood, severe pain
and disability precede both the workers and employers realization that RSI is the problem. Employers and workers tend to
ignore RSI until it hurts both economically and bodily, which
means that many people get worse while they work, and continue to work with pain until their problems cause severe injury
and can no longer be ignored. These injuries are substantially
underreported. And, of course, there are economic consequences
as well: money that should be allocated for prevention of injury
is lost to higher labor and medical costs after injuries occur.
This book is for the reader who wants to benet from my
clinical experience with RSI and my years of treating people
who have it. It was written for people who want to learn how to
effectively deal with this illness and are willing to do the work
required to get better. Youll learn why RSI is such a complex
Introduction
disorder. Youll learn the causes of RSI and how it affects the
body and mind. Ill show you what the latest treatments are, and
how to choose the right health professionals to help you carry
them out.
I have examined more than four thousand patients with
repetitive strain injury. I have learned that RSI is a neuromuscular illness that primarily involves the upper body and that medical specialists often have difculty diagnosing it. There is no
quick x for RSIa sad truth that some of you already know. If
you want to act, rather than be acted upon, you will have to
understand much more about RSI than you now know. There
are very few health professionals who have the whole picture on
RSI and even fewer who know how to treat it by the latest methods. Remarkably, there is so much misinformation on RSI that
you may be learning more about your illness through this book
than you have learned from many of your health professionals.
Once you take the time to learn some medical facts about the
disorder, you can become your own effective advocate in discussing RSI with those who treat you.
1
Understanding
RSI
New opinions are always suspected, and usually opposed,

without any other reason but because they are not already
common.
John Locke, An Essay Concerning Human Understanding, 1690
To catch RSI before it becomes a more serious or debilitating

illness, it is important to recognize its early signs. There are
many risk factors, and every worker should know them. If you
understand what happens to the soft tissues as posture deteriorates, you have come a long way toward understanding RSI.
This disorder is insidiousit creeps up on you over a period
of weeks, months, or even years. Often patients only recall the
day they couldnt take the pain anymore or couldnt continue to
work. The process is like a dam that slowly lls with water and
then suddenly overows. In a survey of nearly ve hundred of
my patients, the most common early signs of RSI were aching or
pain in the forearms or hands, numbness and tingling in the
hands, weakness in the arms, and spasms or twitching in the
forearms. The physician evaluating a person with RSI needs to
get a detailed history to assess these symptoms.
10
Repetitive strain injury is not a diagnosis, but a term used to

describe a very complicated, many-faceted soft tissue problem.
One reason why RSI is so complicated is that the pain or symptom site is not necessarily where the problem lies. You need a
complete physical examination to nd out the true cause of the
problem.
When you see hundreds of patients, it becomes easier to
understand how the many combinations of factors can come
together to create RSI. Still, your symptoms may be unique, and
unless you get a thorough examination, your physician may not
nd the cause of your RSI. Without knowing the cause, there
can be no effective treatment.
Just as a combination of numbers in the right order is necessary to unlock a safe, so the successful combination in RSI
requires the right procedures in the right order. This usually
means a complete physical exam, biomechanical and ergonomic
intervention, a prescribed treatment program of physical or
occupational therapy including a home exercise program, and
psychological intervention when needed.
This book devotes a chapter to each of these topics, and our
goal is to give you enough information to enable you to get the
treatment you need. Essentially, RSI is the result of stress, strain,
overuse, and overloading of soft tissues, causing one muscle
group to work against another. Sometimes, quirks or anomalies
in your anatomy can make you more likely to get injured. How
these combine to cause RSI is most easily grasped by beginning
with the bodys anatomy.
Basic Anatomy
Below are brief descriptions of the most important terms in
anatomy that you will come across when you begin seeking help
for RSI. Take the time to read this and you will become knowledgeable enough to discuss soft tissue injury with any health
professional. Any term not dened here will be found in chapter
2 or the glossary.
Understanding RSI
11
The Skeletal System

The skeletal system is the framework that supports the soft tissues. Usually the skeletal system is not directly affected in RSI,
with the exception of its most severe complication, late stage
reex sympathetic dystrophy/complex regional pain syndrome
clavicle
scapula
humerus
radius
ulna
carpal bones
metacarpal bones
phalanges
Figure 1. The skeletal system of the upper

extremity, the framework that supports the
soft tissues
12
(RSD/CRPS), where bones lose calcium. The ravages of time,

arthritis, or injuries to the skeletal system can also make RSI
worse.
The Spinal Column

The spinal column has thirty-three individual vertebrae separated by cushioning discs, and it divides into ve sections. The
upper three sections are movable, while the lower two are xed.
The upper vertebrae connect with one another to form a strong,
movable pillar for the support of the head, neck, and trunk. Vertebrae also form a protective ring through which the spinal cord
travels to and from the brain. The side arches of two adjacent
vertebrae form tunnels (foramina) through which nerves from
the spinal cord exit and travel to all parts of the body and return
from peripheral sites. If a foramen is partly closed because of
injury or arthritic changes, it can squeeze the nerve ber, causing
dysfunction of that nerve. With a slipped disc, the same type of
sup articular process
body of vertebra
pedicle of
vertebral arch
vertebral
foramen
transvers
foramen
transvers process
spinous process
lumina of vertebral arch
third cervical vertebra
Figure 2. The spinal column has thirty-three vertebrae separated by cushioning discs.
The vertebral foramen is a protective ring through which the spinal cord travels from the
brain.
Understanding RSI
13
compression occurs where the nerve exits or enters the spinal

column. These types of injury are called radiculopathy.
Nerve compression occurs in RSI, usually because of poor
posture. After the nerves leave the spinal column they can get
caught between tight muscles. This can happen in three areas: in
muscles of the neck (scalene muscles), in a space between the collarbone and your rst rib, or in a tight space under the smaller
pectoral (chest) muscle. When this occurs it is called neurogenic
thoracic outlet syndrome (TOS) or brachial plexopathy.
The Shoulder, Back, Neck, and

Upper Arm
Your shoulder is the hub around which your arm and hand
move. The upper arm bone (humerus), as it rotates in the shoul-
trapezius m.
levator scapulae m.
rhomboid mm.
supraspinatus m.
clavicle
infraspinatus m.
teres minor m.
humerus
teres major m.
deltoid m.
triceps brachii m.
Figure 3. The main musculature of the shoulder and back. The shoulder is the hub
around which the arm and hand move.
14
der socket, forms the most mobile joint in your body. Usually, if
posture is poor, the shoulder joint doesnt function properly.
When normal shoulder use is lost, the forearm and hand must
do more work. Impaired shoulder movement is common in RSI
and is a major contributor to symptoms.
The Forearm and the Elbow

As you can see in gure 4, the upper arm and the forearm meet
to form the elbow joint. The elbow joint exes, extends, or
rotates the forearm palm up (supination) or palm down (pronation). Repetitive movement can irritate the ulnar nerve at several
ulna
ulna
radius
Figure 4. Supination
and pronation are
mainly a function of
the elbow, although
supination is also
controlled by the
biceps when the arm
is extended.
radius
supination
pronation
Understanding RSI
15
points, as it runs from the spinal column through the neck muscles, under the collarbone, then over the rst rib and under the
small pectoral muscle. The nerve then passes through a bony
notch at the elbow joint on its way to the hand. The ulnar nerve
normally glides or moves in the neck area. If the nerve is
pinched at the neck due to poor posture and tight muscles, then
it loses its ability to glide and is pulled tightly through the elbow,
causing traction and nerve damage. Think of the ulnar nerve as
a long rubber band that is caught and stretched at the neck and
that must stretch even tighter as you bend your elbow. This
overstretching or traction is called cubital tunnel syndrome. The
ulnar nerve can also be caught at the wrist, where it is called ulnar
tunnel syndrome.
A less frequent injury, radial tunnel syndrome, happens when
another nerve in the arm, the radial nerve, passes by the elbow,
then through muscles and ligaments, where it can get compressed. The main difference between these syndromes is that
cubital tunnel syndrome happens when the ulnar nerve passes
and is stretched around bone, while radial tunnel syndrome happens when the radial nerve passes through tight soft tissue and is
squeezed.
The third major nerve in the arm is the median nerve, which
can be compressed at the carpal tunnel in the wrist, causing
carpal tunnel syndrome. This same nerve can also be compressed by
muscles below the elbow and is then called pronator muscle syndrome, which can be mistaken for carpal tunnel syndrome.
The Wrist
The wrist is a complex structure, and a stable and mobile wrist is
important for normal use. Fractures, dislocations, or tears of the
ligaments of the wrist bones can lead to instability and pain. So
can osteoarthritis of the wrist joints. In patients with RSI, wrist
mobility is often impaired because the forearm muscles contract
and tighten due to injury.
On the palm side of the wrist, there are nine wrist exor tendons, which must pass through the same tight carpal tunnel as the
radius
ulna
carpal bones
metacarpal
bones
phalanges
Figure 5. The wrist is a complex structure consisting of an intricate relationship between

the forearm and the hand.
median nerve
median nerve
transverse carpal
ligament
transverse
carpal
ligament
Figure 6. The transverse carpal ligament acts as a pulley guiding the nine exor tendons
of the ngers. The median nerve travels through the same space, making it vulnerable to
the injury seen in carpal tunnel syndrome.
16
Understanding RSI
17
median nerve. The combination of shortened muscles in the forearm and tightened tendons at the wrist can cause friction, leading
to inammation, pain and swelling, and carpal tunnel syndrome.
Lying next to the carpal tunnel along the fth nger side of
the wrist is the ulnar tunnel (Guyons canal). The ulnar nerve
can be pinched as it passes by a hooklike bump on the hamate
bone of the wrist. This is called ulnar tunnel syndrome.
Nerves
Nerves play an important role in RSI because it is the nerves that
get trapped or pulled in the injured soft tissues, causing pain, the
most common symptom of RSI. Nerves carry pain messages
from the site of tissue damage to the brain and have a critical role
in muscle regeneration. In the most serious injuries of reex
sympathetic dystrophy/complex regional pain syndrome
(RSD/CRPS), the sympathetic branch of the involuntary nervous system, which regulates basic body functions, triggers severe
symptoms of pain, temperature and skin color change, swelling,
and sweating. And, of course, all this affects motor function.
Muscles
Muscles are the engines that drive all of the movements in the
body. For muscles to do their job, they must be well supplied with
nutrients and must be connected to functioning nerves. Good performance requires that muscle attachments to tendons, ligaments,
and bones are intact and that the joints they move are in good
condition. Muscles that are not in balance with other muscles can
instigate events that can cause damage to soft tissues. The cascading factors in postural deterioration damage nerves, other soft
tissues, and ultimately many other muscles of the body.
Tendons and Ligaments

Tendons are attached between muscle and bone and carry
the movement of the muscle to the bone. Tendons are dynamic
18
structures with a rich supply of nerves that permit you to perceive the degree of tension when you move. This perception of
tension is called proprioception. Tendons also have specific
blood supplies, which can vary in different areas of the tendon.
The areas with less blood supply are more likely to be injured
when subjected to sustained, repetitive forces.
The term ligament implies that things are tied together, and
ligaments do in fact tie muscle to bone, bone to bone, and bone
to other soft tissue. But ligaments are also dynamic structures
that play an active role in maintaining joint stability and sending
signals to the brain regarding their status, another example of
proprioception. Ligaments control the limits of joint movements
and prohibit exaggerated ones.
Anomalies or Quirks of the Body

Anomalies or quirks are anatomical structures that are not typical in most people. In RSI they cause difculty by disturbing normal nerve function or making body movement inefcient. The
quirk usually known as double-jointedness is one of these. Double-jointedness can be found in the elbow, hands, and ngers,
making retraining and therapy more difcult because of the lack
of stability in these joints. Double-jointedness is more common
in women. People who are double-jointed have to work harder
Figure 7. Hyperlaxity, or double-jointedness, in the ngers, makes it more difcult to

stabilize the hand while working.
Understanding RSI
19
Figure 8. Double-jointedness at the elbow in a young woman
to keep their nger joints stable and curved over their keyboard.
Scalene bands are another anomaly. These are brous bands
formed between the scalene muscles in the neck. They are only
detectable during surgery and are thought to occur in up to 60
percent of the general population. When these bands are present, they create bridges of tissue over which the nerves are
stretched and irritated, causing them to stick and not glide as
necessary. Thoracic outlet syndrome (TOS), a major problem in
RSI, can be caused by these bands.
Anatomy Is Not Always Destiny

There is a saying in medicine that Anatomy is destiny. In RSI,
most anatomical problems can be adequately treated by correcting imbalances in the soft tissues and working around anomalies. With a proper approach to treatment, most of these
imbalances are reversible. Steadfast attention to postural retraining, physical and occupational therapy, lifestyle changes,
ergonomic and biomechanical modication, and a personal commitment to home exercise programs have proved very effective
in my patients.
20
When the problem is severe and long-term, some soft tissue

injuries may be irreversible. When there is severe damage to tissues, healing may never be complete because of scarring, impairment of circulation, or nerve injury. The sooner RSI is
diagnosed and treated, the quicker and more complete the comeback. Surgery should be the last resort in most cases.
The Most Frequent Symptoms

of RSI
Here are the most common symptoms found in 485 of my
patients. Some of the subjects had multiple simultaneous
symptoms.
Pain, aching, spasm in extremities: 329 (68 percent)
Hand and nger numbness: 55 (11 percent)
Weakness and fatigue: 44 (9 percent)
Tenderness/swelling/inammation: 43 (9 percent)
Tingling in the ngers: 42 (9 percent)
Tightness/stiffness/rigidity of upper body and neck: 34 (7
percent)
Loss of motor control: 5 (1 percent)
What Your Examination

Is Likely to Reveal
Typically, there are several ndings for any patient with complaints related to RSI. Well list the most common here.
Poor Posture
By far the most frequent physical nding in RSI is a characteristic postural misalignment. Typically the head, which weighs
Understanding RSI
21
about 10 pounds (as much as a bowling ball), is thrust or cantilevered forward and stretches and weakens the upper back and
neck muscles, which in turn react by going into a chronic state of
contraction. Changes occur in the upper back muscles as they
attempt to compensate for this added, constant burden. This
cascades into the shoulders, which become hunched and pulled
forward. Other muscles in the front of the body such as the
scalenes, sternocleidomastoids, and pectoralis minors react by
shortening, which sets the stage for nerve damage.
Thoracic Outlet Syndrome

The next most common physical nding is neurogenic thoracic
outlet syndrome (TOS). Some people argue that it is more
anatomically correct to call it thoracic inlet syndrome (TIS), but
well stick to the more common term to avoid confusion. As the
nerves emerge from the spinal column, they combine into networks. Poor posture causes a soft tissue obstacle as the nerves go
through the shortened and tightened scalene muscles. These
muscles act like a pair of pincers, squeezing the nerves and
causing numbness, tingling, and weakness. This diminishes the
ability of the muscles in the extremities to recuperate. In RSI
there is a continuing cycle of poor posture leading to nerve damage, which leads to even worse posture and further nerve and
muscle compromise. If you understand this process, then you
understand how RSI can cascade from minor aches and pains to
a totally disabling syndrome. To reverse the processand it can
be reversed for most peoplerequires your dedication and that
of your therapist or therapists.
Reex Sympathetic Dysfunction

The nerve traction injury of TOS can also involve the sympathetic nerves (involuntary nerves) of the upper body, because
the sympathetic nerves become part of this network of nerves in
its lower portion near the collarbone. Sympathetic nerve bers
22
automatically control glands, blood vessels, and smooth muscles. The sympathetic nervous system is part of the autonomic
nervous system and therefore is not under our conscious control. Patients hands are cold and sometimes sweaty, and their
perception of pain is usually very high. This condition is called
reflex sympathetic dysfunction. Rapid intervention is important,
because these patients are nearing the more serious complication
known as reex sympathetic dystrophy/complex regional pain
syndrome (RSD/CRPS). See chapters 2 and 5 for more on this.
Loss of Shoulder Range of Motion

The shoulder is the most mobile joint in the body. Many of my
patients have evidence of shoulder range of motion impairment,
which is related to postural misalignment. This restricted shoulder movement becomes painful when extreme movements are
attempted. Correcting these conditions is critical because performing activities with limited shoulder movement shifts the
workload to the more delicate forearm and hand muscles. Bicipital tendinitis occurs when the tendons of the biceps muscle
become irritated in a groove at the shoulder. Postural misalignment is usually associated with this condition.
Cubital Tunnel Syndrome

Cubital tunnel syndrome is far more common than carpal tunnel
syndrome. As we follow the ulnar nerve down the arm to the
elbow from the neck, we come to an area where the ulnar nerve
must pass over a bony cleft or notch at the elbow, which is covered
by an arched ligament, creating a tunnel (the cubital tunnel). If the
compression at the elbow persists even for just a few months, it
can cause a painful condition known as tardy ulnar nerve palsy.
Carpal Tunnel Syndrome

The median nerve runs from the elbow down to the wrist,
where it encounters another anatomic tunnel made up of bone
Understanding RSI
23
and an all-important inelastic roof called the transverse carpal ligament. The heavy trafc through this tunnel consists of nine tendons, blood vessels, and the median nerve, which at this point
supplies the thumb, index, and middle nger. The transverse
carpal ligament (roof) acts like a pulley against which the tendons glide or rub as they move to curl the ngers. The symptoms of carpal tunnel syndrome include sensory complaints
such as night pain or numbness and tingling in the rst three ngers of the hand. Grasping and pinching are sometimes difcult.
Radial Tunnel Syndrome

Radial tunnel syndrome, also called supinator syndrome, is most
likely the result of traction and compression of the radial nerve as
it enters a tight canal near the elbow. Basically, the nerve gets
caught between two layers of the supinator muscle on its way to
the hand. This can result in deep forearm pain followed by gradual st weakness. This same area is affected in tennis elbow.
Medial Epicondylitis (Golfers Elbow)

The most common form of tendinitis in persons with RSI is
often called golfers elbow. The medial epicondyle is the bony
bump at the elbow, where the tendons of the pronator muscles
attach. Repetitive pulling on the tendon insertion (where the
tendon enters bone) by a damaged or contracted muscle causes
inammation and results in extreme tenderness when pressure is
applied.
Lateral Epicondylitis (Tennis Elbow)

Slightly less common than medial epicondylitis in persons with
RSI, lateral epicondylitis has similar origins. It occurs in persons
who pursue activities with their wrists extended, such as typists,
tennis players, and guitarists. Excessive pull at the lateral epicondyle bony bump by tendons can cause inammation and
pain. About 30 percent of the time, tennis elbow and radial
24
tunnel syndrome occur simultaneously, leading some health professionals to call it resistant tennis elbow. When radial tunnel
syndrome occurs alone, it can be mistaken for tennis elbow.
Only thorough clinical evaluation can clear this up.
DeQuervains Tenosynovitis
This is a form of tendinitis of the muscles that move the thumb.
As the thumb changes direction in use, it can irritate the tendons
as they pass through their sheaths, causing inammation and
pain. People who continually lift one thumb to accommodate the
extensor pollicis
brevis
abductor pollicis
longus
Figure 9. DeQuervains disease. DeQuervains disease is a tenosynovitis at the base of

the thumb that affects the abductor pollicis longus and the extensor pollicis brevis. It is
characterized by the inammation, thickening, and tenderness of these tendons and
their sheaths.
Understanding RSI
25
other thumbs use of the space bar, who hit the space bar too
forcefully, or who grip their mouse too tightly are at risk for
DeQuervains tenosynovitis.
Myofascial Pain Syndrome

When muscles are injured, they release chemicals that stimulate
nerve fibers, causing pain, soreness, and contraction in the
hands, forearms, neck, and upper back. With more severe
injury, swelling and inammation occur. Myofascial pain syndrome is a common nding in people with RSI.
Now you have a broad picture of the typical ndings in RSI.
The next chapter discusses how to help your physician get the
diagnosis right.
2
Getting the
Diagnosis
Listen to the patient. Hes giving you the diagnosis.

attributed to William Henry Osler (18491920)
Over the years, I have become more perplexed about what

medical specialty is likely to have physicians trained to evaluate
patients with RSI. RSI is a soft-tissue neuromuscular illness, but
there is no soft-tissue medical specialty. This illness is difcult
and time-consuming to diagnose. I have spent as many as two
hours on each rst-patient visit to do a full history and complete
upper-body examination. Many health care professionals may
be less than enthusiastic about doing a complete examination
because of time constraints and the complexity of the illness.
Hand surgeons and orthopedists, who often see RSI patients,
have been trained to treat illnesses surgically. Generally, RSI is a
nonsurgical illness, and though many surgeons recognize this,
not all do. Therefore, in choosing a physician, one should look
for a specialist who can evaluate an occupational illness with
an open mind. After you see your primary care physician, you
may be referred to one of the following specialists: an occupational medicine specialist, a hand surgeon, a physiatrist (physical
27
28
medicine specialist), a neurologist (nerve specialist), a rheumatologist (arthritis specialist), or a pain management specialist. In any
case, you want a physician who understands your illness and is
able to plan your treatment, refer you to the proper therapists,
and follow you through your recovery.
Questions You Need to

Get Answered
Does your physician believe RSI exists? This seems rather basic,
but there are physicians (and many others) who dont believe
this is a disorder at all.
Is your physician listening to you, and is he or she sympathetic? This diagnosis depends heavily on reports from the
patient. A health care professional who isnt willing to listen
carefully is unlikely to be of much help.
Is your physician willing to spend the time necessary to do a
hands-on physical exam? A physical exam is an absolute necessity. If your doctor isnt willing to undertake one, you have to
nd a doctor who is willing.
Is your physician willing to talk to you about his or her ndings, explain them to you, and outline a treatment plan? You
have to understand the plan to be able to carry it out. Halfbaked or hasty explanations will not do the trick.
Will your physician advocate for you with your employer
and insurance carrier? Not all employers and insurance companies are sympathetic. You need a professional advocate, and
your doctor has to be willing to do this for you.
What Your Physician Should

Be Looking For
The ultimate goal is to get you adequately examined, diagnosed, and referred for treatment and therapy. This section is
Getting the Diagnosis
29
not intended for self-diagnosis, but only as a guide to what

should be happening when you visit the doctor.
Evaluation begins with a complete medical history. If you
can, prior to your rst visit write down all you know about how
and when your symptoms began; this will be useful to your doctor and will create a common language between the two of you.
It is important to include information about your working conditions, type of work, intensity of work, and time spent doing
various tasks. Also important is information regarding what
kinds of repetitive tasks you engage in at home, at recreation, or
at sports.
What you can no longer do as a result of your symptoms is
important. Your past medical history, any illness or accidents
you have had including car accidents, medications you are taking, your sleeping, eating, and exercise habits, and any eyesight
problems should also be included. Dont forget to mention any
stress you are under, from any source, and how it may be affecting your emotions.
Specic work information will be needed about keyboard
use, input devices, seating, and monitor placement, plus environmental factors such as lighting, glare, ventilation, and crowding. How and when you use your laptop computer and input
devices, as well as phone use and any difculty you have with
handwriting, are also important. Photographs or videotapes of
you at your workstation are helpful.
This is the kind of information you must provide so the
physician can complete his or her history. Certain basic diagnostic and lab tests that are typically done by your primary care
physician should be part of your history package.
To guide you, on the next few pages is a questionnaire I ask
my patients to complete before they come to our facility.
Patient Questionnaire
Patient name _________________________________
Age ______
Sex M ____
F ____
Occupation ____________________
Height ____
Weight ____
Hand dominance R ___ L ___ Eye dominance R ___ L ___

General health history: Please list any past or current health problems, surgeries, or upper-body injuries with dates.
_______________________________________________________
Current medications ______________________________________

_______________________________________________________
Sleep well? ___ Yes ___ No
Appetite good? ___ Yes ___ No
Do you smoke? ___ Yes ___ No
Do you exercise? ___ Never
____#/day
___ Occasionally
___ Regularly
(describe) ____________________________________________
Current problem:
Chief complaint (current symptoms) _________________________
_______________________________________________________
Date of onset ______ Initial symptoms ______________________
Description of circumstances
When are symptoms most prevalent ___ A.M. ___ P.M.
___ During work ___ After work ___ Constant
What doctors have you seen for this problem? (If more than two,
please list on the back)
Date _____ M.D. name _____________ Specialty ____________
Diagnosis _______________
Treatment _____________________
(continued)
30
Date _____
M.D. name _____________
Diagnosis _______________
Specialty ___________
Treatment _____________________
Please list any tests performed, and provide copies of results (e.g.,
EMG, MRI, blood work, X-rays) ____________________________
_______________________________________________________
_______________________________________________________
Did you ever wear splints? ___ No ___ Yes ____ At work
___ To sleep Duration? _________________________________
Do you drop things frequently?
___ No ___ Yes
Had physical or occupational therapy for this problem?

___ No ___ Yes Duration? _____________________________
Have activities of daily living been affected? ___ No ___ Yes
___ Driving
___ Opening jars
___ Dressing
___ Vacuuming
___ Doing dishes

___ Opening doors
___ Carrying bags
___ Writing
___ Holding books/turning pages
___ Using scissors
Other __________________________________________________
Computer workload: Average hours at keyboard per day ________
___ Straight input
___ Bingework
___ Phone
___ Voice-activated
___ Editing
___ Mixed use
___ Filing
___ V.A. type
___ Intellectual use

___ Writing
___ Mouse
How often do you take breaks? _____________________________

Duration? _____________________________________________
What do you do on a break? ________________________________
Workstation Setup:
Type of keyboard _________________________________________
Type of mouse _________________
Is it at keyboard height? ___ Yes ___ No
(continued)
31
Patient Questionaire (continued)

Adjustable chair ___ Yes ___ No
___ Seat pan tilt ___ Lumbar support
Adjustable desk ___ Yes
___ No
___ Keyboard tray
Adjustable monitor ____ In front of keyboard

____ To right
Copyholder ____ None
____ Left
____ To left
____ Right
Frequently on the phone while typing or writing? ___ Yes

___ No
Do you use a headset? ___ Yes
___ No
More than one workstation? ___ Yes ___ No

Describe _____________________________________________
General work conditions (lighting, ventilation, stress factor,
etc.) ___ Good ___ Fair ___ Poor
Have you reported your symptoms to your employer?
___ No
___ Yes
What was the response? ___ Good (open to changes)

___ Noncommittal ___ Hostile
Other intensive use of hand ___ Gardening
___ Musical instrument: _________________________________
___ Handcrafts ___ Other ______________________________
Hrs. per week _____
Injury: On the job ___ Date ______

Date ______
Sports ___ Date ______
Auto accident ___
Other ___ Date ______
Additional comments _____________________________________

_______________________________________________________
32
33
The Pain Pictogram

Since pain is the main reason why people seek help, a pain pictogram like the one below is very useful to graphically show your
pain pattern to your physician and therapists. Many patients
have told me that lling out the pictogram is the rst visualization
they have of their pain sites. By grading your pain level on a scale
from 1 to 10 in each area on the pictogram you will give perspective to the examining physician about your condition.
The Physical Examination

Most of the ndings in RSI are revealed via a comprehensive
physical examination. Because medicine has become highly
specialized, physicians are losing their hands-on clinical skills,
ANTERIOR
right
POSTERIOR
left
left
right
Figure 10a and Figure 10b. Patients are asked to mark the gures for pain (*), aching (**),
burning (), stiffness (+), and numbness (++).
34
and a general physical examination is less frequently performed

than in the past. Modern-day medicine encourages reliance on
laboratory studies and tests to make diagnostic decisions. In
RSI, however, a negative EMG or MRI may not reect the positive ndings seen in the clinical part of the examination. Some
testing is necessary in certain circumstances, but no test can substitute for a complete upper-body physical exam. The useful
tests are outlined later in this section.
Physicians are beginning to recognize the importance of the
hands-on physical exam. The National Board of Medical Examiners (NBME) and the Federation of State Medical Boards
(FSMB) are pushing for a Clinical Skills Assessment Examination
(CSAE) as part of the U.S. Medical Licensing Examination.
While groups representing medical students are theoretically in
support of the need for enhanced clinical skills, they have
objected to the cost and inconvenience of taking such a test. Ironically, it is the high cost of medical education that has pushed
many students into specialty medicine, where the financial
rewards are usually greater. This has resulted in fewer students
moving into primary care, where a clinically skilled physician
could actually help avoid incurring many of the high costs associated with specialty care. This is especially true in RSI. In my
view, the single factor having the most impact on the cost and
quality of care in the diagnosis and treatment of RSI is the lack of
clinical skills of the physician. Even if the clinician had these skills,
he would be thwarted by the lack of nancial incentive to perform
the kind of examination required to carry out focused treatment.
This has also resulted in patients, in order to seek a cure, visiting
many physicians in a variety of specialties, leading to mounting
costs and a large number of unnecessary surgeries and other
treatments. It is encouraging that some attention is being focused
on improving the clinical skills of students and practitioners.
The objective of the physical examination is to provide as
accurate a set of clinical diagnoses as possible. The following section identies areas of your upper body that need to be examined. We will get to more specic ndings later in this chapter.
The progression in an upper-body exam usually begins with the
35
hands and progresses up to the shoulders, upper back, neck, and

head. There are so many items in a clinical RSI examination
that I always use a printed protocol to guide me through the
examination.
Hands
The hands are examined for nger length, double-jointedness,
swelling, tenderness, tremor, skin color, and condition. Temperature changes, especially cold hands and sweaty palms, are often
overlooked and are important, as they indicate abnormality of
the involuntary nervous system. Contraction of the muscles of
the hand, causing cupping of the palm when the hand is at rest,
conrms that there are nerve and muscle ber changes. DeQuervains disease is veried by Finkelsteins test. This test is performed by having the patient make a st with the thumb placed
inside the palm. The wrist is then laterally exed toward the fth
nger (ulnar deviation), thus stretching the thumb tendons,
which, if inamed, will elicit pain at the base of the thumb. This
pain indicates a positive diagnosis. The hands are also checked
for the presence of ganglion cysts, trigger ngers, and functional
anomalies such as Linburgs tendon, where tendons of the
thumb and index nger are abnormally attached. Finally, the nger strength (pinch test) is performed. This is done with an
instrument called a dynamometer, which measures the strength
of the ngers in various positions.
Wrists
Wrist evaluation should focus on range-of-motion testing in exion (wrist bent downward) and extension (wrist bent upward). If
loss of range of wrist motion is found, it usually suggests that you
have shortened forearm muscles. Neurologic testing for carpal
tunnel syndrome and ulnar tunnel syndrome is performed. Tapping over the nerve to elicit tingling (Tinels test) is helpful for
detecting nerve irritability. In carpal tunnel syndrome we look
for muscle wasting. Phelans test is recommendedthis increases
pressure on the median nerve by bending the wrist in exion for
36
a minute, and producing numbness. If there is any doubt, electromyography should be performed to document median nerve
compression. If the muscle reaction is delayed by more than four
milliseconds, the test is positive. Yet negative results do not rule
out carpal tunnel syndrome. Muscle testing is useful especially
for ruling out median nerve compression farther up the arm
(pronator syndrome) or anterior interosseous syndrome.
Ulnar tunnel syndrome is diagnosed in a similar fashion,
checking for swelling, particularly that caused by a ganglion.
Loss of motor function is more common in ulnar tunnel syndrome than in carpal tunnel syndrome. Nerve conduction velocity studies can be helpful in detecting compression between the
wrist and the hand muscles.
Forearms
Forearms are examined for muscle soreness, tenderness, and evidence of muscle tightness. If these muscles are tight, they jump
like plucked violin strings as the examiner runs a thumb across
them. Grip strength is tested by using an instrument called the
Jamar dynamometer, which records grip power in pounds per
square inch. The instrument can be adjusted for smaller or
larger hands.
Figure 11. The Jamar Dynamometer for testing grip strength
37
Elbows
Elbows are tested for
range of motion, which
should be measured in
extension (straight out),
flexion (bent at elbow),
supination (palms up), and
pronation (palms down).
Elbows are also tested for
tendinitis
and
nerve
impingement by palpation,
tapping (Tinels test), or
electromyography.
The carrying angle,
which is the angle between
the humerus and ulna
12. This womans carrying angle at the
bones, is examined (see Figure
elbow is increased.
chapter 9). This is important because your carrying angle determines how your arms are
positioned at the keyboard. People with a carrying angle greater
than ten degrees probably need an angled or split keyboard.
Shoulders
Shoulder examination is extremely important but often neglected. Shoulder examination should include testing for range of
motion, which is measured for internal rotation, external rotation, abduction, adduction, forward exion, forward extension,
and horizontal flexion and extension. The shoulder is also
examined for evidence of bursitis, bicipital tendinitis, instability,
impingement, and rotator cuff strain or tear.
Rounded shoulders, often combined with a protruding neck
or head, can lead to muscle imbalance that will compress and
stretch nerves. This is the rst step in a cascade that leads to
the problems encountered in the forearms and hands of people
with RSI.
38
Posture
Postural misalignment is one of the pivotal ndings in persons
with RSI. It is essential to check for shoulder protraction (round
shoulders). Stiffness or immobility of the cervical or thoracic
spine can frequently be foundthey become immobile because
of spasm of the muscles supporting the spinal column. Protruding scapulas (winging) may be observed because of weakness of
the muscles that stabilize the shoulder blades. This usually
occurs if the patient is deconditioned, or the nerves supplying
the scapular stabilizers are compromised. Finally, upper trapezius muscles adjacent to the neck tighten as a compensating reaction, since these muscles are recruited to do the work of the
failing upper back muscles. The road back will mean that posture should be corrected and poorly functioning muscles
strengthened and brought back to full activity.
Scoliosis, or a crooked spine, is often hereditary, but should
be looked for since it can contribute to muscle imbalance.
Neck
The neck is checked for range of motion for exion, extension,
rotation and lateral exion, and a forward head position. You
are checked for pain, which occurs when thumb pressure is
exerted at the base of the neck above and below the collarbone
(mechanical allodynia).
Neurologic tests such as
the Roos (Elevated Arm
Stress Test) test, Wrights
test, and mechanical allodynia for thoracic outlet
syndrome are performed.
Figure 13. Thumb pressure

testing for mechanical allodynia
39
Tests
Often insurance companies and lawyers may demand what they
consider objective tests such as EMGs or MRIs, even though
many of the physical exam tests are also objective. Patients may
urge that tests be done to reassure themselves that a catastrophic
illness is not lurking in their bodies. It is up to the examining
physician to determine if and when they should be done. Speaking to patients about these ndings is important.
Here are some of the tests that might be ordered. Many do
not have a direct relationship to RSI, and this list is by no means
comprehensive.
Roos Test
Also known as the EAST test, elevated arm stress test, this
involves placing the patients arms in the hold-up position for
three minutes. It is a reliable test for bringing out symptoms
such as weakness, numbness, and tingling in people who
have neurogenic thoracic outlet syndrome.
Wrights Test
This has a similar rationale. It involves extending both arms
straight up, which produces symptoms by stretching or pulling
on the nerves in the neck, or possibly a loss or a diminution of
the wrist pulse.
Mechanical Allodynia
Allodynia means that pain occurs from a stimulus that ordinarily would not produce pain. Mechanical allodynia involves the
therapist pressing on a muscle and its nerves with the pad of the
thumb. The impaired tissue releases pain-producing substances
helpful in diagnosis.
40
Other Tests
Cervical radiculopathy (see pages 5556) is suspected when
pain is elicited by applying downward pressure on the exed
neck. If pain is elicited, further tests such as cervical spine X-rays,
CT scans, and/or MRI would be indicated. Cervical radiculopathy as a cause of neck pain is far less common than brachial
plexopathy. In other words, in people with RSI, the soft tissues
of the neck are more likely to cause nerve trouble than the bony
or cartilaginous structures. With increasing age, radiculopathy
becomes more common.
Muscle Testing
It is also useful to test muscle strength to nd the areas where
weakness occurs because of nerve and/or muscle damage. In
TOS this muscle damage and weakness will usually be found in
the hands and forearms.
Clinical Nerve Testing

Look for Tinels sign, where the physician taps on the nerves
with his ngersat the elbow or the wrist, for exampleto see if
you feel tingling or pain. Test for deep tendon reexes with a
reex hammer. Perform the Semmes-Weinstein monolament
test for sensory loss. Test for two-point discrimination for nerve
progressive status.
Diagnostic and Lab Tests

I stress the importance of a complete physical examination for
people suspected of having RSI. Certain basic diagnostic and lab
tests that are typically done by your primary care physician
should be part of an RSI examination. For a number of reasons,
the examining physician may feel compelled to perform additional tests. If an accompanying or contributing illness is suspected, such tests can aid in the diagnosis.
41
Biofeedback
Biofeedback furnishes the examiner and the patient with information on the state of bodily processes such as skin temperature
and heart rate through the use of a machine with electrodes
attached to the body. The test usually involves an auditory or
visual response through which the patient can gain some voluntary control over the bodily process. Biofeedback is also useful
in the treatment of reex sympathetic dysfunction as well as RSI
and low back syndrome, and can provide feedback during biomechanical retraining sessions.
Bone Densitometry
This test is used to determine loss of bone mass in conditions
such as osteoporosis or osteopenia.
Bone Scan
Scan is a short term for scintiscan. It maps the bones by
illustrating the concentration of gamma rays emitted by an
injected isotope that seeks out bone. Osteoporosis and bone
tumors can be detected by this technique. Scintiscans can be
obtained for other body organs when organ-specific isotopes
are used.
Computerized Tomography
(CT Scan)
Computerized tomography has replaced plain X-rays in a number of different areas. It has revolutionized diagnostic radiology.
CT scans utilize low doses of X-rays and then computerize the
absorption of X-rays by tissues such as the brain skull and
spinal uid to create images of these tissues that resemble actual
slices through the body. Contrast medium is sometimes injected
to enhance the quality of the image.
42
Electrocardiography (ECG)
ECG is a test that measures the electrical activity of the heart
muscle. It is useful in distinguishing the chest pain of heart disease
from that of TOS, and detecting irregularities of heart rhythm.
Electromyography (EMG)
Like an electrocardiogram, EMG measures the electrical activity
of muscle. Normal muscle is electrically silent at rest. By inserting a needle into muscle and observing the quality and quantity
of action potentials that occur when muscle is contracted, deviations from the norm can be detected. A renement of this technique is used for demonstrating focal dystonia (writers cramp),
which is sometimes seen in musicians and typists. Here a thin
wire is inserted into individual muscle bundles to demonstrate
an abnormal muscle contraction pattern. The latter technique is
used primarily as a research tool.
Electroneurography (Nerve Conduction

Velocity or NCV)
This test is used in RSI patients to demonstrate compression of
a nerve such as the median nerve in carpal tunnel syndrome or
ulnar nerve traction at the elbow in cubital tunnel syndrome. In
these syndromes, slowing of the electrical impulse along the
motor nerve ber is seen. It is less useful in demonstrating
the soft tissue nerve compression in the neck caused by
thoracic outlet syndrome, because of the number and density of
the nerve roots. Since TOS is clinically so common in RSI, a
negative result in NCV testing can divert the physician from this
important diagnosis. Because of variability in standards, this test
is only as good as the person performing and interpreting it.
Infrared Camera Analysis

The infrared camera allows the examiner to detect real-time
changes in skin temperature during movement. Presently very
43
few facilities have this equipment. In the future, it may prove

extremely useful to confirm the diagnosis of reflex sympathetic dysfunction (RSD) or complex regional pain syndrome
(CRPS).
Magnetic Resonance Imaging (MRI)

This truly revolutionary technique does not require X-ray exposure. MRI uses a magnetic eld to obtain a detailed picture of
the bodys soft tissues. It is useful for investigating the soft tissue
injury that characterizes RSI. If the patient has a cardiac monitor, pacemaker, or surgical clips in the brain, a CT scan must be
done instead.
Plethysmography
This test measures the intensity of pulse waves in various parts
of the body. It is useful in detecting arterial compression when
the patient changes position, as might occur in thoracic outlet
syndrome, when blood vessels are compressed.
Positive Emission Tomography

(PET Scan)
This technique is performed in nuclear medicine facilities and is
not available in all hospitals. Like CTs and MRIs it involves
slicing or cross-sectional data-gathering. At present it is specifically used to investigate the brain, heart, and lungs. It is not a
frequently used test in RSI patients except where there is suspicion of a coexisting illness.
Surface Electromyography
(Surface EMG)
This technique uses a number of electrodes placed over muscle
groups to analyze muscle contraction. It is also a useful biofeedback tool.
44
Thermography
Thermography uses infrared imaging to locate skin temperature differences in various parts of the body. It is considered
important in the management of chronic pain and in the diagnosis of reex sympathetic dysfunction and complex regional
pain syndrome. It is available in only a few facilities. Some centers have an improved version capable of computer-assisted
thermography.
X-rays (Radiographs)
X-rays are electromagnetic vibrations of short wavelengths.
They penetrate some substances more readily than others and
act on photographic lm. They are useful in RSI to detect bone
problems such as osteoporosis, fractures, and anomalies. X-ray
analysis is less useful for evaluating soft-tissue problems.
Vibrometry
This test is used to test the sensitivity of peripheral nerves that
might have been damaged by a vibration injury. Generally, computer users dont get vibration syndrome, although recent studies have shown evidence that this does occur in some. If you
have been engaged in other activities involving vibration, this
test can also be helpful.
Blood Tests
The following are blood tests that are done to rule out various
illnesses, also listed here, that might be contributing to RSI
symptoms:
Chemical profile: cholesterol, triglycerides, and liver and kidney functions, among others
Complete blood count (CBC): anemia, infection, and disorders
such as leukemia, lymphoma, Hodgkins disease, and lupus
45
Erythrocyte sedimentation rate (ESR): infection, arthritis, arteritis, and anemia

Blood sugar: diabetes mellitus
Cholesterol and triglycerides: coronary artery disease
Serum iron and iron binding capacity: anemia and iron transport
diseases
Rheumatoid factor: arthritis
Antinuclear antibodies (ANA): lupus, connective tissue disorders, scleroderma, rheumatoid arthritis
Thyroid hormone levels and thyroid stimulating hormone (TSH):
thyroid disease, hyperthyroidism, hypothyroidism
Electrolytes (potassium, sodium, calcium chloride, phosphorus):
various metabolic deciencies
Proles of Injury: The Signicant

Findings in RSI
To get a broader picture of RSI it is helpful to look at a large
group of RSI patients. This section proles the ndings found in
RSI patients that I have seen in the past few years of my practice
and covers the most significant diagnoses I found in these
patients.
In my group of RSI patients, 70 percent used the computer
for most of their workday. About 25 percent were musicians who
were injured primarily from playing their instruments. The
remainder were in professions where repetitive tasks were common. When rst seen, almost 60 percent were working full-time
despite symptoms. Sixteen percent had lost their jobs due to RSI,
and 1 percent were receiving disability payments. That so many
people in pain were still at work suggests that the stereotype of
the malingering employee should be rethought and that many
workers injuries are not reported to the workers compensation
system.
46
How RSI Begins

In RSI, early recognition and early treatment mean quicker
recovery. In 56 percent of my injured patients, aching, pain, and
spasms in the extremities were the rst signs of RSI. Patients
generally used the term spasms to describe twitches, while a
few used this term to describe muscle tightness. Ten percent
also noted hand and nger numbness, while weakness, fatigue
tingling, and stiffness occurred in about 6 to 7 percent. Less
frequently, tenderness of the muscles and vague discomfort were
reported. About 18 percent did not recall details of their rst
symptoms. RSI usually develops slowly, so it is understandable
that some people will not recall the early signs of their illness.
However, most of my patients came to our facility within a year
of the onset of their rst symptoms. Increase in pain is the
principal reason why people with RSI nally seek care. In some
cases, a marked increase in numbness and tingling, weakness,
and muscle tenderness and swelling is the trigger for seeking
help.
Postural Misalignment
The most frequent physical nding in patients seeking care for
RSI is postural misalignment. I found this in almost 80 percent
of my patients. Generally, as we age, our posture deteriorates,
an outcome even more likely if weve spent years hunched
over a keyboard or performing a variety of other repetitive
tasks without preventive upper-body conditioning. In postural
misalignment, the head, thrust forward, stretches and weakens
the upper back and neck muscles. The shoulders are hunched
and pulled forward, and muscles in the front of the body react
by shortening, setting the stage for nerve damage. As nerves
emerge from the spinal column (where they might be compressed by a disc or a bone spur, causing radiculopathy), they
combine into networks called the cervical plexus and brachial
plexus.
47
A
B
C
Figure 14. Progressive postural distortion/decompensation with neurovascular compression.

A: Normal resting posture. B: Shoulder protraction beginning; sternomastoid muscles are shortening, drawing head anteriorly and inferiorly. C: Advanced deformity with adaptive shortening of
scalene and smaller pectoral muscles. Note narrowed costoclavicular space as well (ribs 1
through 5 have been relatively elevated). Neurovascular compression is evident at all three sites.
Neurogenic Thoracic Outlet

Syndrome (TOS)
In this syndrome, nerves encounter a series of tight spots as they
travel from the neck to the arms and hands. The brachial plexus
nerves encounter what is their rst soft-tissue obstacle in the scalene muscles. Two of the three scalenes act like a pair of pincers
when they are shortened and tightened and can squeeze the
brachial plexus nerves. Since the scalene muscles are also
attached to the upper ribs, they can affect breathing if they are
tight. Stretching these tightened muscles to relieve pressure on
nerves is a basic component of treatment and should be accompanied by breathing exercises. About 70 percent of RSI patients
will have this diagnosis.
Once the nerves emerge from between the scalene muscles,
the next tight spot they encounter is between the collarbone
(clavicle) and the rst rib. With the tightened scalene muscles
pulling the rst rib up, the space between the collarbone and the
rst rib narrows, to become another area of potential pressure on
48
the nerve bundle as it descends to the arm. At this point, the

nerve bundle is joined by vascular structures and encounters
another tight spot as it goes under the pectoralis minor muscle
along the upper chest. With postural misalignment, these muscles
will be shortened, tightened, and painful to pressure (see gure
14). Occasionally the tightened pectoralis minor muscles can compress the large arm artery (subclavian artery) so that when an
arm is raised above the heart, a loss of pulse occurs. This can usually be remedied by a course of stretching and postural retraining.
If nerves are compressed in any of the above-mentioned areas, the
nerve bundle will lose its capacity to slide, undergoing pulling or
traction as you move your arms. This is a very common injury,
which I have found in 70 percent of my patients.
A number of anatomic quirks, which we may be born with,
can predispose us to developing TOS. The most common are
scalene muscles that are enlarged or attached too far forward on
the rst rib. Sometimes brous bands of tissue can bridge the
scalene muscles, resulting in a tethering of these nerves, which
then cannot glide as they should. Between 30 and 60 percent of
the general population have these bands. Bony abnormalities
such as an extra rib are less common anatomic quirks. People
with a long neck and drooping shoulders can also be at risk for
TOS. Whiplash injuries appear to cause TOS in certain cases,
and migraine headaches can accompany TOS. In my experience
this is a neglected cause of migraines.
Because the brachial and cervical nervous networks involve
so many different nerve branches, and encounter so many softtissue obstacles related to poor posture, injury to various areas
of these nerves can present different symptoms. Knowledge of
these symptoms can help the examining physician locate the site
of nerve compression or traction.
Superior trunk injury causes pain radiating into the shoulder
down the arm and along the central portion of the shoulder
blade (see gure 15). This can cause swelling in the face and neck
as well as atypical severe migraine headaches not responsive to
the usual migraine medications. This is an easily missed diagnosis, as it is often confused with ordinary migraine headaches.
49
cervical plexus
superior trunk
middle trunk
inferior trunk
medial cord
lateral cord
posterior cord
radial n.
musculocutaneous n.
median n.
ulnar n.
Figure 15. The cervical plexus and brachial plexus are the keys to understanding RSI and its
pain patterns.
Medial cord injury causes pain in the front portion of the

neck, which radiates down the forearm to the fourth and fth
ngers.
Inferior trunk injury causes dull aching pain in the forearm,
with tingling or burning of the fourth and fth ngers, as well as
weakness of the thumb muscles and intrinsic hand muscles. This
lesion is the most common form of neurogenic thoracic outlet
syndrome.
Lateral cord injury causes severe pain in the area below the
collarbone and tingling of the thumb, index, middle nger, and
50
occasionally the palm. In this case, chest wall pain can be misdiagnosed as a cardiac event such as a heart attack.
Posterior cord injury causes tingling or burning over the triceps muscle of the arms as well as the tennis elbow area (lateral
epicondyle). Sometimes tingling and burning are felt in the forearm, thumb, index, and middle ngers.
TOS traction injuries can also cause reex sympathetic dysfunction. This involves the sympathetic nerves of the upper body
because they become part of the nerve network near the collarbone. The sympathetic nervous system is part of the autonomic
or involuntary nervous system and is not under our conscious
control. Sympathetic nerve bers control glands, blood vessels,
and smooth muscle. About 20 percent of the patients I examined
with TOS had manifestations of sympathetic overdrive. Their
hands were cold and sometimes sweaty, and their pain level was
increased. This condition is usually called reex sympathetic dysfunction. Here, rapid intervention is important. Muscles and joints
should not be immobilized with splints, and an aggressive physical
therapy program should be undertaken along with an appropriate medication. This condition may lead to the more severe
complication known as reex sympathetic dystrophy (RSD),
which is now called complex regional pain syndrome (CRPS).
Failure to recognize or improper treatment of reex sympathetic dysfunction can develop into reex sympathetic dystrophy/complex regional pain syndrome (RSD/CRPS). It is critical
to realize that any soft-tissue injury can result in RSD/CRPS, a
severe evolutionary phase of sympathetic overdrive. The injury
can be caused by excessive typing or other repetitive movements;
trauma, such as getting your hand or arm caught in a door; or
occasionally from operations, such as a carpal tunnel release or
other surgery. Early and aggressive treatment is essential.
RSD/CRPS is usually divided into three stages, as suggested
by neurologist Robert J. Schwartzman, M.D.: stage I, in which
there is increased sensitivity to touch and heat stimuli; stage II,
in which symptoms increase in intensity and pain spreads; and
stage III, in which pain can spread to lower extremities or the
other side of the upper body.
51
Two patients I recently saw illustrate the need for the examining physician to be alert. Unfortunately, in both cases they
came in six months after their precipitating episode, and both
were in stage II, when treatment measures are far less successful.
A. B. was a fifty-year-old woman, a hardworking office
supervisor who performed her tasks with no obvious difculty.
She did have a history of Lyme disease, for which she received
antibiotics over a six-year period. One day, as she was going
through a doorway, her hand got caught in the push bar of the
door. She pulled away abruptly. She sustained both a crush
injury to the hand and a pulling or traction injury to the brachial
plexus. Both of these injuries were potentially precipitating
events for RSD/CRPS. She was disabled because of the delay in
her treatment caused by the late diagnosis.
The same was true for C. F., a sanitation worker whose hand
was injured while he was at work. He, too, sustained a crush
injury to his hand and a traction injury to the brachial plexus. His
pain was so severe that a light touch to his skin produced paroxysms of pain. The lesson here is that the diagnosis of this disorder
needs to be made early. This requires a high degree of suspicion
by the examining physician, who should obtain the necessary
information from a thorough history and physical exam.
As to the illness progress, visible tissue changes occur in the
upper extremities and include thickened and shiny skin, brittle
and cracked nails, contracted joints, and calcium loss in the
bones. In the later stages of evolution, patients with RSD/CRPS
become weak in the affected muscles, which develop spasm,
increased irritability, and exaggerated tremor. At this stage it also
is difcult for RSD/CRPS patients to initiate movement.
Therapeutic intervention with physical therapy and certain
medications should be started immediately with the assistance of
a pain management specialist, who might enlist a more aggressive approach to treatment, such as nerve blocks, which are most
effective in the rst six months. See chapter 5 for more details.
Cubital tunnel syndrome occurs in more than 60 percent of
the people I examined. The ulnar nerve runs from the neck to the
elbow, where it must pass under a bony cleft or notch through a
52
tunnel roofed over by an arched ligament at the elbow. As the

elbow is bent, greater pull or traction is exerted on the nerve. If
the ulnar nerve is locked in place at the neck, as occurs in TOS,
then bending the elbow will distress the nerve at this second
point; some call this a double crush. This is why I recommend
use of the hands and forearms with the elbow open instead of at
a right angle when using the keyboard. Tardy ulnar nerve palsy
occurs when the ulnar nerve remains injured for a long time,
causing muscle weakness. A ganglion cyst in the cubital tunnel is
another possible reason for ulnar nerve compression.
Ulnar tunnel syndrome (Guyons canal syndrome) describes
yet another potential area of compression of the ulnar nerve; this
occurs at the wrist in a tunnel adjacent to the carpal tunnel. We
found this syndrome in about 10 percent of our patients. Symptoms include pain, numbness, and tingling in the third, fourth,
and fth ngers; these symptoms are aggravated by bending the
hand upward at the wrist (wrist extension).
There are many potential causes of ulnar tunnel syndrome,
ranging from anatomic abnormalities to fracture of the hamate
bone (a wrist bone), to riding bicycles with awkward handlebars, to arthritis. In typists and musicians, this may be due to
repetitive wrist extension coupled with windshield-wiperlike
bending of the hands at the wrist.
Median Nerve Injury

Pronator Teres Muscle Syndrome
Here the median nerve, which also derives from the brachial
plexus, is squeezed between the two heads of the pronator teres
muscle below the elbow. This is the muscle that moves the forearm and hand into the palms-down position used in typing and
piano playing. The median nerve winds its way through several
forearm muscles before entering the carpal tunnel. Since the
median nerve has a branch that goes over the wrist before entering the carpal tunnel, injury to that nerve segment can cause sensory disturbances over both surfaces of the hand. In pronator
syndrome, numbness of the whole palm is the important distin-
53
guishing feature; in carpal tunnel syndrome, usually just the

thumb, forenger, and middle nger are involved.
There are many possible causes of pronator syndrome.
Trauma and muscle inammation of repetitive movement probably play a major role in what we see in computer users. We
have found this syndrome in 6 percent of our patients.
Carpal Tunnel Syndrome
It is very important to distinguish the symptoms of carpal tunnel
syndrome from those of pronator syndrome to avoid inappropriate surgery. We hear a lot about carpal tunnel syndrome,
which is often misused as a synonym for RSI. Although EMGs
and NCVs are considered to be the diagnostic gold standard,
research has shown that the most reliable way to diagnose carpal
tunnel syndromes (CTS) is a pictogram of the hand lled out by
the patient. Actually, I have found this syndrome in about 8 percent of my patients, and have rarely sent anyone with CTS for a
surgical release unless there was atrophy of the muscles at the
base of the thumb and the palm (the thenar eminence), which
indicates more advanced damage involving the motor branch of
the nerve.
The symptoms of carpal tunnel syndrome include sensory
complaints in the hands and ngers such as night pain, numbness, and tingling. Grasping and pinching are sometimes difcult. The trafc through the carpal tunnel consists of nine nger
exor tendons, blood vessels, and the median nerve, which supplies the thumb, index, and middle nger (see gure 6). The
transverse carpal ligament, or roof of the carpal tunnel, acts like
a pulley against which the tendons glide or rub as they move to
curl the ngers. Picture a shing rod with rings through which
the shing line runs; remove a ring and the line bowstrings to
the next ring. This is what happens if the transverse carpal ligament is cut in the carpal tunnel release operation. This places
tension on the next set of pulleys, which are located in the ngers. Trigger finger results from the increased friction and
inammation in these tendons, which can develop nodules or
become inamed and swollen, causing the tendons to get caught
54
in the nger pulleys when the ngers are exed. Surgery may be
necessary to correct trigger nger.
In my experience, patients with carpal tunnel syndrome
almost always sustain a loss of normal wrist range of motion.
This is probably the result of the forearm muscles shortening due
to overuse, combined with a loss of the capacity to regenerate
muscle. Repetitive wrist motion results in a rise in pressure in the
tunnel. Gentle, gradual range-of-motion exercises of the wrist,
coupled with forearm massage and correction of ergonomic
problems, can in most cases obviate the need for surgery.
While carpal tunnel syndrome is regarded as a median
nerve compression problem, in addition to the median nerve,
nine exor tendons of the ngers run through the carpal tunnel.
Since virtually all those with carpal tunnel syndrome lose range
of motion in their wrists because of shortened forearm muscles,
these shortened muscles can be the cause of the greater friction
in the carpal tunnel. The increase in carpal tunnel pressure also
diminishes blood supply to the tendons and the median nerve.
Stretching and forearm muscle massage and strengthening are
important to correct this condition. The question of splints
when and if to use themis discussed in chapter 5.
Radial Nerve Injury

Radial Tunnel Syndrome
Also called supinator syndrome, this is most likely the result of
both traction and compression of the radial nerve as it enters a
tight canal at the elbow, which is sometimes roofed over by a
tendinous arch called the arcade of Frhse. The nerve gets
caught between two layers of the supinator muscle on its way to
the hand. This can result in deep forearm pain, followed by
gradual st weakness and local pain on pressing of the lateral
epicondyle (bony prominence in the elbow).
Radial tunnel syndrome occurs in about 7 percent of my
patients, slightly less frequently than carpal tunnel syndrome.
With appropriate ergonomic intervention, coupled with rest and
physical therapy for radial tunnel syndrome, results are good.
55
Some surgeons propose surgery if there is no improvement after

four months of conservative treatment to forestall permanent
nerve damage. As with all surgery, it should be considered a last
resort. About 30 percent of the time, tennis elbow and radial
tunnel syndrome occur simultaneously, leading some health
professionals to call it resistant tennis elbow. However, when
radial tunnel syndrome occurs alone, it can be mistaken for tennis elbow. Only clinical evaluation can clear this up.
Cervical Nerve Root Compression
Also known as cervical radiculopathy, this is sometimes overdiagnosed as a cause of pain and other symptoms in RSI. There
is a denite tendency to underdiagnose neurogenic thoracic outlet syndrome. I have found cervical radiculopathy in only 0.03
percent of my patients, although this low number may not hold
for a population older than my patients, who had a mean age of
38.5 years. A focused physical exam will usually make the distinction. Cervical radiculopathy usually involves the C5-C7 disc
area in the neck. In cervical nerve root compression, weakness
occurs in muscle groups such as the deltoids, the serratus, rotator cuff, and biceps. In neurogenic thoracic outlet syndrome
(TOS), which usually involves the C7-C8-T1 area of the spine,
weakness occurs in the hand and forearm muscles. Another distinction is that there is a tendency to drop things in TOS
because of weakness in the hand and forearm muscles.
In adulthood, many of us have protruding discs, which may
lead to a diagnosis of root compression when seen on X-ray. A
complete exam and certain specic tests such as MRIs and nerve
conduction studies may be necessary if there is any doubt. It
should not be forgotten that cervical discs and neurogenic thoracic outlet could occur simultaneously. Thus, cervical radiculopathy can occur from acute or chronic hernia of a disc. A disc
is a cushion of cartilage between vertebrae and can be associated
with the slipping of one vertebra over another (spondylolisthesis)
or a bony proliferation occluding the hole (foramen) from which
the spinal nerve exits. Tumors of the cervical cord can also cause
symptoms of radiculopathy. A major complaint is pain, rst in
56
the neck followed by shoulder, forearm, and hand; the pain can
be made worse by exaggerated neck movements, including
whiplash. Diagnosis is made by X-rays, EMGs, CT scans, MRIs
of the spine, and other lab tests and by observing for motor
weakness and diminished deep tendon reexes. A C5C6 disc
lesion produces weakness of the biceps, and a C6C7 disc lesion
produces weakness of the triceps and deltoids.
Clinical diagnosis requires a Spurlings test, where the head is
tilted toward the involved side and pressure is applied to the top
of the head, eliciting pain. If there is a history of whiplash injury
or other injury suggestive of cervical root compression, consultation with a neurologist or neurosurgeon should be sought.
Any manipulation or treatment of the neck before ruling out
cervical radiculopathy might cause serious injury.
Injury to Tendons
Tendons are attached on either end of muscles and transmit
mechanical movement of the muscles to the bone. Tendons are
dynamic structures with a rich supply of nerves, permitting them
to perceive the degree of tension (proprioception), which is transmitted back to the brain or the spinal column. Tendons also have
specic blood supplies, which can vary in different areas of the
tendons. Because tendons are generally smaller in the upper
extremities, they are particularly at risk for inammation (tendinitis). With injury, the exquisitely regular microscopic architecture of the tendon becomes disorganized and is repaired with scar
tissue, which permanently shortens the tendon. When a tendon
tears or is acutely injured, minimal splinting during treatment to
allow some motion of the tendon during healing will keep the
scarring to a minimum. Tendons perform a variety of functions.
One is that they allow several muscles to act on one site. When
tendons become inamed or irritated and swollen from repetitive
movement through a constricting sheath, you have a condition
called tenosynovitis. Outlined below are some of the more common forms of tendon injury that we see in people with RSI.
Medial epicondylitis (golfers elbow), which I have found in
57
more than 60 percent of my patients with RSI, is the most frequent form of tendinitis. Lateral epicondylitis (tennis elbow), at
more than 30 percent, is less common than medial epicondylitis
in people with RSI.
In DeQuervains tenosynovitis we are dealing with a slightly
different mechanism of injury (see gure 9). In this case the tendons are attached to the muscles that move the thumb in an
upward and outward direction. Because the tendons change
direction as they move they can become injured by friction in
the sheath and become inamed.
People who develop DeQuervains18 percent of my
patientsusually engage in biomechanically harmful positioning
of the thumb. Often they raise their thumbs above the space bar
of the keyboard to keep the space bar free for the other thumb,
or they grip the mouse too tightly. Pianists who cross their
thumb far into the palm while doing scales or arpeggios; violinists who grip the neck of the violin tightly to keep it from sliding
off their shoulders; or clarinetists whose right thumb supports
are too low, are all candidates for DeQuervains.*
Flexor tendinitis, or trigger nger, is another common ailment in RSI. The hand has no muscles from the knuckle joint
(metacarpal joint) to the tip of the nger. The mechanism for
moving the ngers relies primarily on muscles in the forearm
attached to long tendons, which form a set of pulleys in the ngers. Inammation of these tendons and their sheaths hinders
free movement of the wrist and ngers and is associated with
stiffness, pain, and loss of range of motion. Awkward positioning and tight gripping can contribute to the development of this
condition, which also can lead to trigger nger.
*An article in the New York Times of April 30, 2002, titled Youth Let Their
Thumbs Do the Talking in Japan, notes an interesting phenomenon. Japanese youngsters are increasingly using Web-capable phones that require the use
of both thumbs to push their buttons. Television stations in Japan have even
held thumb-speed contests, with one woman clocked at a hundred Chinese
characters per minute, the equivalent of a touch-typing speed of a hundred
words per minute. The ultimate effect of this in leading to injury such as
DeQuervains tenosynovitis remains to be seen.
58
Many of my RSI patients had evidence of shoulder range of

motion impairment, which is related to postural misalignment.
The shoulder is the most mobile joint in the body. The ball of
the upper arm bone (humerus) is not enclosed in a deep cup,
like the hip joint. Instead, the upper arm bone rests in a shallow
cup surrounded by a circle of muscles, ligaments, and tendons
that stabilize it and work the joint (the rotator cuff). Tightening
and contraction of these muscles can lead to restriction of shoulder motion. Carried a step farther, this tightening can result in
the head of the humerus being pulled up against the bones of
the scapula and clavicle, resulting in what is called shoulder
impingement. This restricted shoulder movement becomes
painful when extreme movements are attempted. A frozen shoulder occurs when most shoulder movement becomes impossible.
Degenerated muscles and tendons of the rotator cuff can easily
tear either partially or completely during lifting movements or a
fall, causing severe pain. Tears need immediate attention and
possibly surgery.
Correcting these conditions is critical because performing
activities with limited shoulder movement shifts the workload
to the more delicate forearm and hand muscles. I have found
impaired shoulder range of motion in more than 40 percent
of my patients and shoulder impingement in more than 10
percent.
Bicipital tendinitis occurs when the tendons of the biceps
muscle become irritated in a groove at the shoulder. Postural misalignment is usually associated with this condition. I found that
15 percent of my patients had evidence of bicipital tendinitis.
Injury to Muscles
Muscles are the engines that drive all of the movements in the
body. For muscles to do their job, they must be well supplied
with nutrients and must be connected to functioning nerves.
Muscles that are not in balance with other muscles can instigate
events that can cause damage to all soft tissues. Earlier, we
reviewed the cascading factors in postural deterioration where a
59
conict between muscle groups damages nerves and other soft

tissues and, ultimately, many other muscles of the body.
Oddly, little emphasis has been placed on the important role
of muscles in RSI. The lack of sufcient healthy muscle to carry
out lifes functions is ultimately the distinguishing characteristic
of RSI. RSI sufferers have weakness, soreness, and tenderness
in compromised muscles, and as the illness progresses, the muscles contract, leading to nerve compression or traction, loss of
normal joint range of motion, and the entire spectrum of RSI
disabilities.
Muscles are highly complex, sensitive structures that have
exquisite capabilities to adapt to a variety of uses. Lift weights to
gain strength, and old muscle bers will be broken down and
replaced with new bers, more capable of sustaining increased
loading. This phenomenon is known as the degeneration/regeneration cycle. For muscle to regenerate normally, nerve stimulus,
an adequate supply of the stem cells called satellite cells, good
blood supply, and certain hormones are necessary. If one or more
of these factors is lacking, muscle regeneration will be thwarted.
The way in which muscles are used can accelerate injury.
Consider the person with RSI whose posture has caused nerve
dysfunction and who with repetitive motion is therefore tearing
down muscle bers at a prodigious rate but who now has limited
capacity to regenerate new muscle. This is something we often
see in people who use their bodies in a biomechanically poor
fashion, increasing the likelihood of injury. The more of this kind
of malpositioning, the more potential for injury. This type of
muscle activity leads to disruption of the muscles calcium metabolism and produces disorganization of muscle structure.
When muscles are injured they release chemicals that stimulate the nerve bers, causing pain. Palpation of muscles in the
hands, forearms, neck, and upper back reveals soreness and contraction. With more severe injury, swelling and inammation
occur.
These manifestations of muscle injury are sometimes called
myofascial pain syndrome, implying that not only muscle but
also its surrounding cover (fascia) have sustained injury. I have
60
found some form of myofascial pain syndrome extremely common in RSI and it was found in most of my patients.
Fibromyalgia
The term bromyalgia, now part of the medical lexicon, is difcult to dene and is surrounded by controversy. Most of the
time there seems to be no cause for the condition, though it has
sometimes been linked to surgery or trauma. Janet Travell, who
became famous as John F. Kennedys physician, identied a
series of trigger points or tender areas that cause pain when pressure is applied. Symptoms of bromyalgia include muscle stiffness and pain, fatigue, headaches, abdominal distension,
diarrhea, and bladder irritation. The American College of
Rheumatology has endorsed diagnostic criteria relating to eighteen painful points where muscle, tendon, and ligament attach to
bone. If eleven of these painful points are noted, especially when
accompanied by other symptoms, a patient is said to have
bromyalgia.
Since these points are located where tendons insert into
bone, they are probably related to muscle tightness and imbalance. Causes may include mental or physical stress as well as
anxiety and depression. Fibromyalgia is reported most frequently in women. Treatment is no different from what I propose for RSI: a team approach with physical or occupational
therapy, a home exercise program, psychological counseling,
and use of medications where indicated.
Injury to Ligaments
The term ligament implies a tying together, and indeed ligaments tie muscle to bone. But ligaments are also dynamic
structures that play an active role in maintaining joint stability
and sending signals to the brain regarding their status (proprioception). Ligaments control the limits of joint movements, prohibiting exaggerated actions. In the early stages of child
development, ligaments undergo tissue modication to become
spinal discs and joint surfaces.
61
Loose ligaments can destabilize joints. For example, loose ligaments create greater risk of injury by making it more difcult
for double-jointed people to maintain a stable hand. I have
noted a high incidence of hyperlaxity of nger and elbow joints,
especially in women. In certain ngers and in the elbows, the
incidence is well over 50 percent. People with RSI who are
hyperlax need biomechanical retraining to teach appropriate
positioning of the hand and the ngers, so as to create a more stable arch of the ngers. Long ngernails will make this impossible; they must be cut to a length no greater than one-sixteenth of
an inch. People with hyperlaxity of the elbows and other joints
must be careful not to overstretch these joints when exercising.
Ganglions
If you develop a lump or a bump in the hand, it is probably a
ganglion cyst. These are soft-tissue blowouts, which can occur
on the tendon, the tendon sheaths, or the cells lining the joint.
They look like a round bump under the skin. Most of the time
they do not produce symptoms, but sometimes they can put
pressure on nerves, especially in the Guyons canal or the cubital
tunnel, where they cause nerve compression. The top or dorsum
of the wrist is where I have most commonly found ganglion cysts
Figure 16. A ganglion cyst is a common location for these tendon-related soft-tissue
blowouts.
62
(about 13 percent). There is no harm in leaving them, unless

they are compressing a nerve or an artery.
Linburgs Tendon Anomaly

Because I have found Linburgs tendon anomaly in 13 percent
of the people I have examined, I believe this is worth noting.
Linburgs tendon is an extra slip of tendon connecting a exor
tendon of the thumb to a exor tendon of the index nger.
When you pull the thumb toward your palm, it causes curling of
the tip of the index nger. Conversely, if you grasp the tip of the
index nger, it can prevent the thumb from moving toward the
palm. This condition can sometimes cause problems in nger
action for computer users or musicians. Biomechanical rehabilitation can prevent the problems associated with this anomaly.
TFCC Tears
If a patient with RSI complains of pain in the ulnar portion of
the wrist, I consider the possibility of a perforation or tear of
the stabilizing wrist structure at the joint between the radius
and the ulna bones. This is called the triangular brocartilaginous complex (TFCC). A TFCC tear can occur in people who
have had a previous wrist fracture or a traumatic wrist dislocation. It can also result from excessive frequent movement, from
pronation to supination. Pain in the ulnar portion of the wrist
is a frequent complaint. Although computer use or other repetitive tasks do not usually cause a TFCC tear, it affects the quality of work and should be considered in a patient history.
Diagnosis is conrmed by MRI. Treatment, which should be
undertaken by a hand specialist, will vary based on the character of the lesion.
Other Injuries
While not directly related to RSI, the ligament of the thumb
known as the ulnar collateral ligament can sustain a tear, partic-
63
ularly among people with joint hyperlaxity. Ulnar collateral ligament tear is sometimes called gamekeepers thumb, because it
was rst described in gamekeepers, whose work included twisting the necks of small game. It commonly occurs from a fall on
an outstretched hand or in a fall with the strap of a ski pole in
the hand. This tear can be disabling because it causes instability
of the thumb while typing or gripping a mouse. If the disability
is severe, surgery may be indicated.
Pain caused by the supercial branch of the radial nerve, or
Wartenburgs syndrome, is rareIve seen it in only three of
almost ve hundred patients, twice in relation to tight splints
used to treat carpal tunnel syndrome. Occasionally the supercial branch of the radial nerve can be compressed, giving rise to
numbness, burning pain, and night pain along the back of the
wrist, in the thumb, and in the web space between the thumb
and index nger. Even the touch of clothing in this region can
produce tingling. In another case, a tight wristwatch band was
the cause. This injury to the radial nerve has been reported as a
complication of the surgery for DeQuervains disease.
Thrombophlebitis in Computer Users:

Economy Class Syndrome
A potential threat to computer users who spend long
hours seated at a desk is the possibility that they will
develop thrombophlebitis, or blood clots in the veins of
the legs. This is similar to what has been reported in airline passengers who take long ights in cramped economy class seats. Although considered rare in computer
users, it may be more common than previously thought.
Both Richard Nixon and Dan Quaylehardly typical economy class iersdeveloped this illness.
Ordinarily, sitting for a long time may cause small clots
to develop that gradually dissipate after you get up and
move around. An extreme example was reported by a
group of physicians from New Zealand who wrote about a
thirty-two-year-old man who spent up to twelve hours
64
daily at his workstation, hardly ever getting up. He began

to notice swelling in his calves followed about ten days
later with shortness of breath, a sign that some clots had
broken off and migrated to his lungs. He soon became
unconscious, and was hospitalized. Tests conrmed the
clots in his lungs. He survived, but needed more than six
months of treatment with anticlotting medications. Other
physicians have reported seeing people with similar symptoms. A London physician speaking recently to reporters at
Reuters Health Information says we may be seeing more of
this illness, especially if we look for it during examination.
It should be stressed, however, that this complication may
be relatively rare. To avoid thrombophlebitis, computer
users should take a break every hour, get up, walk around,
and do some basic foot and leg exercises. Taking hourly
breaks will also benet vision and general muscle function.
Computer users should note that coexisting illnesses such
as diabetes or a heart condition might increase the risk of
economy class syndrome.
Getting the Diagnosis Right

Unusual symptoms can present a serious challenge to the evaluating physician. One of my patients, B. Z., was a thirty-ve-yearold woman whose work involved about six hours daily at a
computer, most of it combined with speaking to clients on the
telephone. Apart from an auto accident two years previously,
which resulted in a whiplash injury, B. Z. was in good health.
The neck pain from the whiplash resolved in a few days and did
not bother her subsequently. Her troubles began when she
decided to paint her bedroom by herself. She spent several
hours with a brush in her right hand while holding the paint can
for part of the time in her left hand. The following day she
noticed the onset of a headache on her left side. The pain was
piercing and over the next few days got worse, extending over
her eye and on the left side of her face and neck. It was accom-
65
panied by numbness and tingling. Over time the symptoms

migrated down her left arm. After about a week the headache
was so severe that she was unable to work. Acetaminophen and
NSAIDs gave little or no relief. B. Z. sought help in her local
emergency department, and after a perfunctory exam, an ER
physician gave her some commonly used preparations for
migraine headache. Despite the medication, her headache persisted. She then sought the help of her HMO plans primary
care physician, who after hearing her symptoms called a colleague neurologist who said that her symptoms didnt make
any sense and that she was probably a hysteric, a label often
directed at women when the diagnosis is not textbook-clear. As
her symptoms persisted, she saw the chief neurologist at her
HMO. As she had not lost strength in her upper body function
to any great degree, he ruled out a stroke and sent her for an
MRI, suspecting multiple sclerosis. But the MRI and other tests
were negative, and he told her it was probably in her head
(which it was!) and gave her no further appointments. She was
still in considerable distress when we saw her. The clinical tests
for neurogenic thoracic outlet syndrome, none of which had
been performed by any of her physicians, were dramatically positive on her left side, and she was long-necked with drooping
shoulders, which are risk factors for neurogenic TOS. After several weeks of physical therapy and home exercises her symptoms abated, but even when symptom-free, when she did
overhead chores she noted a strange feeling, which would go
away if she did more intensive stretching.
This case illustrates several issues. First, the need for a complete physical exam in such cases; second, the need for even specialists to rely on their clinical expertise when performing these
exams; third, the importance of obtaining a thorough historyin
this case, the whiplash injury might have set the stage for the
later injury; fourth, the need for health professionals to know
about the link between neurogenic thoracic outlet syndrome and
migrainelike headaches; and fth, the responsibility of the health
professional to avoid accusations of hysteria before ruling out
every possible physical cause for unpleasant symptoms.
66
The lesson: RSI and its complications can often be mistaken

for emotional or neurological disease. If the cause of the symptoms is not obvious to the examiner it can easily be sorted
out by a methodical clinical approach and some basic clinical
tests. RSI is a very complex illness with many possible ndings,
which can usually be discerned through a thorough physical
evaluation. These ndings are the bases for diagnosis, which
establishes the rationale for a focused, team-oriented treatment
program. Though a complete upper-body physical may reveal
some of these conditions, periodic general examinations should
be part of your normal health regimen.
The case of Mr. C, a fty-year-old manager in a small electronics company, illustrates the complexities of the physical
examination of a patient with upper-extremity symptoms. Mr.
Cs work entails a good deal of stressful customer relations,
about two to four hours of computer work, and about two
hours a day of driving. He is a nonsmoker who has been in generally good health. Eleven years prior to his visit he noted some
neck pain and shoulder discomfort, which led him to see a chiropractor. While undergoing a manipulation on his neck, Mr. C
felt a sudden popping accompanied by severe and sudden
pain. X-rays and CT scans of the neck revealed that a ruptured
disc was protruding and compressing his spinal column at the
C5C6 level. He suddenly lost the normal curvature of his cervical spine due to muscle spasm. A week after this occurrence,
Mr. C underwent discectomy, the surgical removal of the rubbery disc between adjacent bony vertebrae. The two adjacent
segments were fused as part of the operation, resulting in the
loss of exibility between the C5 and C6 vertebrae. Cervical
degenerative disc disease is about a fth as common as low back
disc problems. The C5C6 level in the neck is where this most
commonly occurs.
Mr. C may not have been given a sufcient period of conservative management before resorting to surgery. Conservative
management would have included a neck brace, rest, pain medication, and focused physical therapy including home exercises
and possibly psychological intervention. It might not have
67
worked for Mr. C, but probably it should have been the initial
approach. Following this surgical intervention, pain diminished
but did not disappear. This residual pain was described as different. Several months later, an evaluation revealed the presence
of another protruding disc at the C6C7 level. This time conservative treatment was followed. Physical therapy exercises were
prescribed and were helpful. Over several years Mr. C experienced increasing pain affecting the upper extremities. Gradually
his activities became more restricted. He could no longer drive
comfortably, and he gave up gardening and most sports, but he
continued to work. He restricted his ofce work to three days a
week to minimize his driving. As his life became more restricted
he saw a number of physicians who recommended a variety of
treatment approaches while always assuming his symptoms were
from his disc-related cervical radiculopathy. His pain then took
on a burning quality, particularly in the lower neck area and
shoulders along the upper trapezius muscle. It was more severe
on the left. This seemed to suggest that his sympathetic nervous
system was now involved. Soon afterward he began to notice
that his hands were getting colder, and he began to drop things
from his left hand. Low back pain also ensued due to a compensatory imbalance of the spine, since the entire spine works in a
synchronous fashion. He was given a variety of medications to
control his symptoms, including a gastroprotective NSAID, a
muscle relaxant, and antidepressant medications, including both
an SSRI and a tricyclic (see chapter 5). Despite these measures,
his condition worsened.
At this juncture an evaluating physician should look for new
causes of the symptoms, since many of the new complaints were
not compatible with disc disease alone. Physical examination
revealed a host of new ndings, including clinical signs of neurogenic thoracic outlet syndrome, reex sympathetic dysfunction,
myofascial pain syndrome, golfers elbow, shoulder weakness,
and depression. The results of the physical exam pointed to a
mixed syndrome of a more complex nature, which would make
treatment more difcult. One example of this difculty would be
the treatment of Mr. Cs lack of neck range of motion, which
68
helped to cause the nerve traction and compression of the

brachial plexus. The therapist would be loath to force the neck
into various positions for fear of further damage to the spine.
Instead, soft tissue work would have to be applied to stretch the
neck muscles passively. Next, the weakness of the shoulders,
arms, forearms, and hand would need to be addressed with
stretching and strengthening where indicated. A carefully choreographed home exercise program could then be started.
Mr. Cs condition did improve with this approach, but it
took almost a year of intense therapy. He was nally able to
drive comfortably. He made appropriate ergonomic changes in
his workstation and was careful about pacing himself. Mr. Cs
experience demonstrates the need to recognize that many factors
are at play in those who present with work-related upper-body
disorders. They often pose diagnostic challenges that can only
be solved by a methodical physical exam followed by aggressive
and focused intervention.
3
RSI and Your
Emotions
There can be no transforming of darkness into light and

of apathy into movement without emotion.
Carl Jung, 18751961
Repetitive strain injury is often associated with disabling emotional and psychological problems. Stress, chronic pain, complex
chronic pain, anxiety, depression, and panic are all linked and
can lead to a fearsome chain of events that needs to be broken
before it causes or increases disability.
While most of the emotional and psychological problems we
see result from RSI and the damage it causes, they also can be a
contributing cause of RSI in the rst place. Typically, while
under minimal stress, you might be working long hours at an
ergonomically poor workstation with awkward posture and
positioning, when pain and other RSI symptoms develop. In
this case, stress follows increasing pain, which then leads to anxiety. As the pain and discomfort become more difcult to control, severe emotional problems can develop.
Conversely, someone working long hours in a stressful environment, perhaps having problems with an employer or fellow
69
70
employee, may become stressed and tense. With increasing stress

levels, muscles can become tight, pain follows, muscle injury
increases as work continues, and the harmful cycle has begun.
Surviving the emotional and physical roller coaster of RSI
requires help from professionals who are familiar with this disabling combination. Rarely can you rise above the physical
problems of RSI without having to deal with the emotional
component as well.
Stress
Stress is your bodys reaction to any disturbing physical, mental,
or emotional stimulus. In 1953, Hans Selye described stress as a
basic defense mechanism characterized by ght or ight. Adrenaline levels rise and in turn stimulate the body to secrete hormones to prepare it for an encounter. Dr. Selye described two
kinds of stress: eustress (good stress) and distress (bad stress).
Stress is not always harmful. Eustress is benecial to the body
and can result from moderate physical exercisethe pleasant
rush you feel after a vigorous workout. Distress is the extreme
form of stress. Some examples of distress are excessive exercise,
overwork, or lack of sleep. Distress is likely to lead to anxiety
and depression and in severe instances to panic reactions.
Anxiety Disorders
Anxiety can be heightened by fear about the cause and outcome
of your illness. The best way to begin coping with your anxiety is
to seek a complete evaluation by a knowledgeable physician who
will discuss your problem in depth and put it in perspective for
you. Understanding RSI can be very reassuring and will enable
you to take charge of your situation and begin changing things.
A common fear in RSI is that you can lose your job, your
means of sustenance, and your health. Understanding that there
is a process that you can go through to preserve your health will
RSI and Your Emotions
71
help you deal with the realistic worry and anger you may feel
about these overwhelming occurrences.
Anxiety can involve a variety of circumstances, including
fears of social situations such as public speaking, physical environmental fears such as crowds or cramped spaces, and trauma
such as the soft-tissue injury encountered in RSI or an auto accident. As if in double jeopardy, the RSI patient is at risk for the
effects of job loss or the threat of job loss. Separation or death of
a family member or friend can also contribute to anxiety.
Anxiety disorders have been classified by the American
Psychiatric Association so that they can be better understood
and treated. The classication for anxiety disorders includes the
following:
adjustment disorder with anxious features
acute stress disorder
generalized anxiety disorder
phobic disorders, including specic phobia, social phobia, and
agoraphobia
post-traumatic stress disorder
panic disorder
obsessive-compulsive disorder
With RSI, we are most likely to encounter three of these:
generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), and panic disorder.
If anxiety symptoms come on suddenly, it is important to
perform a medical evaluation, which should include tests for
thyroid and pulmonary diseases such as asthma or COPD.
Drugs that can be misused or overused that can lead to anxiety
include caffeine, cocaine, methamphetamines, thyroid medications, or bronchodilators used for asthma. Alcohol or benzodiazepines, particularly if they are discontinued abruptly, can
result in acute anxiety.
Research suggests that the part of the brain that may play a
role as a mediator for anxiety is the amygdala, an almond-shaped
72
mass of gray matter located in the front part of the temporal

lobe of the brain.
Generalized Anxiety Disorder (GAD)

The association of GAD with RSI is probably more common
than realized. It is also worth noting that many of the symptoms
of GAD are also found in reex sympathetic dysfunction, which
can occur in almost 20 percent of RSI patients. In both conditions there is increased sympathetic nervous system outow,
producing cold, clammy hands, sweating, muscle tension, trembling, twitching, aching, and soreness. Dry mouth, nausea, diarrhea, and urinary frequency are also common.
GAD is characterized by a long-term siege of worry that is
difcult to control and anxiety symptoms such as restlessness,
easy fatigability, irritability, sleep problems, and muscle tension.
The diagnosis of GAD is made by a psychiatrist, but the
intervention of a medical specialist is also a wise idea, since a
medical condition such as alcoholism or drug abuse needs to be
ruled out.
Treatment should be supervised by a psychiatrist, who may
decide to make follow-up referrals to various therapeutic groups.
The inciting cause, such as job loss or injury from a repetitive
motion injury, also needs to be remedied. There are many
medications considered effective for GAD. These include benzodiazepines; tricyclic antidepressants; buspirone, a nonaddicting antianxiety agent; selective serotonin uptake inhibitors
(SSRIs); trazadone; and venlafaxine antidepressants. These
medications should be administered strictly under the supervision of a psychiatrist.
Post-traumatic Stress Disorder

(PTSD)
Soft-tissue injury encountered in RSI might lead to post-traumatic stress disorder, which was studied extensively in Vietnam
veterans. It is being increasingly recognized as a result of many
73
types of injury. The characteristics of PTSD include traumatic

exposure when a person experiences, witnesses, or is confronted
with events that involve serious injury, threatened death, or a
threat to the physical integrity of oneself or others. The person
with PTSD experiences an intense fear accompanied by a feeling of helplessness or horror. Many patients I have seen who are
confronted with repetitive strain injury, combined with loss of
job or difculties at work, t this description.
PTSD is now recognized as a fairly common disorder, with
a lifetime prevalence as high as 8 percent. Women are affected
twice as often as men. As in RSI, once exposed, there is an
increased risk for another episode. Symptoms of PTSD can
include nightmares, ashbacks, emotional numbness, and trouble concentrating. The most effective medications for PTSD are
SSRI antidepressants administered under the care of a psychiatrist who has made the diagnosis.
Panic Disorder
The emotional components related to job loss and stress can
lead to panic disorder. These can occur as unexpected attacks
consisting of acute paroxysms of anxiety. A physician making
the diagnosis would note shortness of breath, rapid heart rate,
light-headedness, sweating, tremor. and nausea. Panic disorder
can even mimic a heart attack. Also characteristic of a panic disorder is a denite feeling of fear and a desire to ee. Women
have a greater propensity to develop it than men, and it generally occurs in the late teens through the thirties. It can be accompanied by agoraphobia, major depression, substance abuse, and
risk of suicide. This can adversely affect quality of life. As with
other anxiety disorders, panic reaction is often unrecognized by
medical doctors.
After diagnosis the managing physician can choose from a
variety of medications added to psychiatric counseling. These
include the benzodiazepines; monoamine oxidase inhibitors;
SSRIs; tricyclic antidepressants; and venlafaxine, which is an
antidepressant unrelated to other groups.
74
Depression
The depression associated with RSI is generally considered a
transient and reactive mood disorder that subsides when the
injury heals. This type of depression is a response to a complex
set of disturbing circumstances such as soft-tissue injury, loss of
self-esteem, job insecurity, nancial problems, or strained relationships with an employer, fellow employees, or family. Even
athletes who suffer an injury in their sport may nd themselves
in depression, which subsides after the healing of their injury.
Depression can be part of the comorbidity picture described
with certain anxiety disorders.
If you are depressed, a stimulant is not the appropriate medication. Depression and stimulants are a dangerous combination
that can lead to paranoid suicidal thinking. Seek help if there are
any signs of depressive behavior.
The incidence of emotional and mental disturbances is high
in people with RSI. A psychiatrist or psychologist can be helpful. Anyone with previous mental health problems may have a
recurrence with RSI. There are antidepressant medications that
are useful in controlling the depression as well as the pain of
RSI. They are discussed in chapter 5.
The rst sign of work-related emotional upheaval would be a
good time to get your problem diagnosed and a treatment program begun. Begin with an emotional assessment as well as a
physical or occupational therapy assessment. Then make sure
you have corrected any ergonomic deciencies at work and that
you pace yourself by taking adequate rest breaks, which will
relieve some stress.
The emotional problems that accompany RSI dont go away
easily, and you may need to have psychiatric or psychological
counseling. Initially it is probably wise to seek the individual
counseling of a psychiatrist or psychologist. This is important,
because professional expertise is necessary to rule out any serious problems that need continuing care. Another important
75
reason to seek the help of a mental health professional is the possibility that you might benet from the use of antidepressants or
other medications. These medications also might increase your
tolerance to pain by raising your pain threshold and making it
easier for you to participate in physical therapy and exercise.
In a professionally run support group conducted by a psychotherapist or social worker, you can nd a safe haven where
you can discuss your problem. The professionals will be able to
determine if there is anyone with a severe emotional problem
requiring medication or a more sophisticated level of care.
There are many peer-run RSI support groups, usually in
major cities. Participating in a group afliated with your workplace is one option, though the privacy of such a group may be
limited.
Information about how to nd these groups is in the Internet
resources section.
4
RSI and Your
Eyes
Dont go looking at me like that, because youll wear your

eyes out.
mile Zola, La Bte Humaine
f you have had any problems with headaches, blurred vision, or

eyestrain, this chapter will help you understand what is happening and help you discuss your eye condition more easily with
your doctor. Like any ne and complex instrument, eyes need
to be cared for and allowed to do their job under the best conditions possible. It is important that any computer user with eye
problems see an eye specialist such as an ophthalmologist. When
you begin sustained work at the computer, you may notice that
your day-to-day corrective lenses wont work as well for you, and
a new lens prescription just for computer work may be necessary.
Eye Checkups
Our eyes were not designed for the strains of ofce work. As a
result, every year millions of people consult eye specialists for
problems that begin with computer use. As early as 1977, a
77
78
Swedish study conducted on airline reservation clerks, showed

that 75 percent of them complained of vision problems, while 55
percent had shoulder and back pain and 35 percent suffered
with headaches and neck stiffness. Is this still the case for present-day computer users? The answer appears to be yes. James
Sheedy, O.D., Ph.D., who is now director of professional development at Sola Optical USA, has reported that 75 percent of all
computer users suffer from a variety of eyesight-related problems, which he ranks in order of frequency:
eyestrain
headache
blurred vision
temporary myopia (nearsightedness)
dry or irritated eyes
neck and backache
photophobia (sensitivity to light)
double vision
afterimages
If you have any of these problems, seek the help necessary
to remedy it. Each of these conditions can probably be corrected
by proper intervention.
Computer Vision Syndrome

Eye problems relating to the use of the computer are sometimes
called computer vision syndrome (CVS). It is said that 60 million people suffer from these eye problems and that the number
is rising by 1 million yearly. Your eyes perform an enormous
amount of work when you use your computer. CVS exists
partly because the image on the CRT computer screen is constantly being reprojected at a rapid frequency (the refresh rate).
(This is not the case with an LCD or plasma monitor.) Print on
paper is more distinct than the images you see on the computer
RSI and Your Eyes
79
sup. rectus m.
ciliary body
iris
optic nerve
lens
cornea
central retinal a. and v.

retina
choroid
sklera
Figure 17. Side view of the eye. Attached internal muscles adjust the lens to change focus.
monitor, which are created by red, green, and blue dots that continually ash on the screen too rapidly for you to detect. So the
refresh rate is far from refreshing. Some other causes of CVS
include long hours at the computer, poor ergonomic setups, and
poor vision correction.
The eye is a complex organ capable of many functions, a
number of which have important bearings on vision at the
workstation. One of these functions is called accommodation.
The closest distance that allows you to focus sharply on an
object is called the near point of accommodation. Internal eye
muscles adjust the lens to make focusing possible. As we age,
lens elasticity diminishes, causing the near point to move farther
away. This is why at about forty years of age, many of us need
bifocals.
You can improve your accommodation by looking down
slightly. If you look up or sideways, the ability to accommodate
diminishes. Therefore, when looking at your computer monitor,
depending on the distance your eyes are from the screen (normally arms length), you should be viewing the center of the
80
Figure 18. Acuity and visual acuity can improve by setting up your monitor so
that you look down at it.
monitor screen at a downward angle. As you see from the illustration on this page, a straight line from the top of the monitor
to the level of your eyes should result in a 15- to 20-degree
downward angle to the center of the screen.
As you get nearer to the screen, a greater downward angle
will be necessary to focus clearly, so avoid neck and back strain
by staying as near arms length as possible. When you gaze
downward at the computer, bend from the hips, not just the neck.
A slight chin tuck can relieve neck strain when looking down.
Another important function is binocularity, which is the
ability of our eyes to fuse the images from each eye into a single,
three-dimensional image. If this function is disturbed and the
image in each eye is seen at different levels, it is called heterophoria, a fairly common condition that is often ignored.
Attempts to compensate for heterophoria can cause tilting of the
head and neck or other awkward postures, resulting in both
neck pain and eyestrain. Your ophthalmologist usually can correct or improve heterophoria.
Another important but often neglected factor is the determination of your eye dominance. You may not be aware of it, but
RSI and Your Eyes
81
you probably favor one eye over the other, just as you may be
right-handed or left-handed. Right-handedness doesnt always
coincide with right-eye dominance. About 40 percent of people
are crossoverstheir eye dominance is the opposite of their
hand dominance. Knowing your eye dominance can help you
adjust your workstation more efciently. A right-handed person
who is left-eye-dominant, yet places the bulk of documents used
in his work on the right, will be turning his or her head sharply
to the right to bring the left eye
into focusing position. If, instead,
the documents are placed on the
left, he or she will do less head
turning. With some kinds of computer work such as data entry, the
user may be more comfortable
with the data placed more centrally and the monitor moved
slightly closer toward the dominant eye. Alternatively, a document holder on the dominant eye
Figure 19. Its easy to gure out your eye
side may be more comfortable.
dominance. Form a small hole between your
index ngers and your thumbs, with arms
If you offset the screen slightly
fully extended. Look at a single object
from center to favor your domithrough the hole formed by your hands and
draw your hands toward your face while
nant eye you may feel more comkeeping your eyes on the object. The hole
fortable, although LCD screens
made by your hands will be in front of your
dominant eye.
may become more difcult to see.
Choosing the Right Visual Tools

Your goal is to achieve visual comfort and visual safety. Choices
should be made with the help of an ophthalmologist or other
qualied vision specialist.
Not everyone will need the same type of correction for computer use. For people with 20/20 vision or better, no intervention
may be required. People who wear lenses have several options.
For near- or farsightedness, with or without astigmatism, simple
82
refraction may be all that is necessary. Those over forty, who need
bifocals because their near point of visual acuity has lengthened,
have several options: ordinary bifocals, progressive lenses, special
computer screen lenses, contact lenses, screen lenses that enlarge
the screen image, LCD projection, or an LCD or plasma screen.
Ordinary bifocals can cause neck and back problems
because they force you to tilt your head back to see the screen
clearly. If you are not a touch typist, you will be in an awkward
viewing position when you look at the keyboard.
Progressive lenses may be slightly better than traditional
bifocals, but like traditional bifocals, may restrict side vision, so
that you may not see the full width of the monitor and adjacent
reading materials. A new type of lens created especially for the
computer user, the Continuum lens, claims to allow the bifocal
user to see the entire workspace more comfortably.
Bifocal contact lenses may offer a slightly greater visual eld
than ordinary bifocals. Contact lens users tend to get dry eyes.
Low humidity can contribute to dry eyes, too. Blinking more
frequently can help, as can articial tears without vasoconstrictors. Blinking reminder programs are available for the computer.
Screen lenses are another visual tool involving the application of a special lens in front of the screen. One type is called the
PC Magni-viewer. However, a larger PC screen can do as well as
a screen lens.
LCD projection or large LCD or plasma screens are tools
that can be used for serious visual deciencies. See the visual
aids section, which follows.
Using only dark letters on a light background can aid eye
comfort. Rest your eyes for several minutes of each workhour
by looking away from the screen or by gazing at distant objects.
Keep your lenses and your monitor screen clean.
To achieve a visually ergonomic workstation, a computer
user should pay attention to positioning, angling his or her monitor correctly, controlling glare, distortion, reection and icker
as well as modifying work lighting if necessary.
Start by having your screen straight up and down (at a right
angle to the desk). The screen is then gradually tilted upward,
RSI and Your Eyes
83
toward your face, until it feels comfortable and you see clearly.
Studies have shown that there is greater comfort and less visual
distortion with this approach, but the upward-facing screen can
produce glare by catching ceiling lights.
There are several ways by which lighting problems can be
solved. Turn off your screen and look for reection and light
sources. Decrease overhead lighting by using a hood for the
screen, something that can be purchased or fashioned out of
cardboard. Reduce glare by directing the monitor screen away
from windows and light sources. Use glare screens if necessary
these are available at computer stores. Indirect lighting aimed
away from the workstation can diffuse light and diminish reection. If you can see ickering on your screen, lower the brightness of the monitor.
Each computer job presents its own challenges to eye comfort at the workstation. These job characteristics were classied
by Professor tienne Grandjean and updated by Stuart B. Leavitt, Ph.D., C.I.E., of Leavitt Communications.
Here are some tips that may help you at your workstation:
Data document entry. The main job here is to read documents
and enter data into the computer system. In this kind of
work, the keyboard and screen are secondary to the document being read. Locate your reference documents centrally, and keep the monitor slightly on the side of your
dominant eye.
Data search/inquiry with data insertion. The Internet user, transcriptionist, and telemarketer all work at the computer in
this manner. Here, attention is directed primarily at the
screen. A telephone is often an additional data source.
Keep the monitor in front of you or slightly to the side of
your dominant eye, and make sure the monitor and keyboard are at comfortable angles. If you work with a phone
at your computer, get a headset.
Interactive use. Travel reservationists and banking personnel,
for example, are involved in data entry and data acquisition at the computer and also must have access to printed
84
documents. Try to align your documents toward the side

of your dominant eye; a document holder attached to the
side of the monitor case is useful here.
Design and graphics. Computer-aided design (CAD), computer-aided manufacturing (CAM), and desktop publishing (DTP) are usually done with pointing devices like the
mouse or puck and a large-screen monitor. Here the keyboard is used less often than the other devices, which creates placement problems. Position the mouse or other
input devices centrally, and place your screen centrally or
slightly to the side of your dominant eye. The large screen
will require a lower position, and a keyboard tray will
keep the keyboard central, but out of the way of the pointing device.
Many employees nd themselves doing a combination of
tasksmultitasking is the word youve heardoften sharing
workstations with colleagues. Freelancers and ofce temps also
move around from workplace to workplace. This type of work is
the most difcult to set up for comfort. Learn your ideal workstation measurements, and carry a pocket tape measure so you
can duplicate your personal measurements wherever you go.
Avoid workplaces where there is no accommodation for some
degree of ergonomic adjustment.
Serious Eye Problems

Coal mines are no place for seventy-year-olds, but computer
terminals are, said Senator Patrick Moynihan in 1999 on the
lifting of earning limitations for Social Security recipients. The
end of wage limitations means that older workers will be reentering the workforce as computer operators. As the workforce
ages, these serious eye problems will become more common.
The yearly eye examination to prevent or delay glaucoma,
cataracts, and age-related macular degeneration is now more
necessary than ever.
RSI and Your Eyes
85
Glaucoma
The most common cause of blindness, glaucoma is an insidious
illness that if detected in its early stages can be managed with
medication to prevent progression.
Cataracts
A common cause of visual impairment, cataracts result from a
clouding of the lens of the eye. As we age, cataracts become
more common, and they advance more quickly if you have diabetes or have a long history of being exposed to ultraviolet light.
Recent advances in treatment such as lens implants have helped
to restore vision.
Age-Related Macular Degeneration

This serious illness has damaged the eyesight of 13 million
Americans. Age-related macular degeneration affects people as
early as their late fties or sixties. Each year, 400,000 more
Americans develop this serious problem. There is no known
cure or lasting treatment. However, many devices are available
to assist people with this condition, allowing them to continue to
work on a limited basis.
Reading devices that magnify documents and project them
onto a screen have been extremely helpful for the sightimpaired. Now there are LCD (liquid crystal display) technology
projectors that hook up to computers that enlarge and project
the monitor image onto a wall or screen. Large LCD or plasma
screens now becoming more popular for TV use can also serve
this purpose. These devices can be costly, but in some cases may
give a legally blind person limited function at the computer.
Partially sighted people might make some use of voiceactivated software, but such software still requires some keyboard use. Voice training is important to teach you how to
enunciate properly, avoid slurring words, and speak more regularly as you dictate. Some software programs actually do this for
86
you, but I usually recommend at least one session with a speech

therapist, who can teach you to use your voice properly to prevent chronic hoarse voice. Placing the microphone properly is
very important, as is recognizing the speed limitations of voiceactivated software. Many systems are on the market, but a properly functioning system will need lots of RAM. There are
several Internet Web sites that can guide you about what to buy,
such as a voice users group at http://www.voicerecognition.net.
5
Managing Pain
Nature has placed mankind under the governance of two

sovereign masters, pain and pleasure.
Jeremy Bentham, Principles of Morals and Legislation, 1789
Pain is the most common complaint in RSI, both in the early

and late stages of the disorder, and its the main reason why people come to see me. Pain tells us that injury is present, and its a
warning signal that shouldnt be ignored. Pain is something only
you feel, and thats why it is difcult to convey its nature and
intensity to others. This is especially true with RSI, because the
afflicted person generally looks healthythere are no open
wounds. If your physician is insensitive or skeptical about your
pain, you risk a worsening of your condition. Seek someone
who cares, who will listen and help guide you to recovery. See
the section on choosing a physician in chapter 2.
As RSI progresses, it becomes more obvious that the
pain associated with it has variable qualities. It may start as
a periodic aching associated with work and may become
more severe, constant, and burning as time goes on. To make
matters worse, other symptoms may arise, such as weakness,
87
88
numbness, depression, anxiety, and panic. As RSI progresses,

pain becomes more difcult to manage, a good reason to begin
early treatment.
The most common type of pain is acute pain, which is usually temporary. It is our rst line of defense against further
injury. If you continue to work with acute pain, tendons, muscles, or joints may become inamed. If you rest and obtain
appropriate treatment, your acute pain usually goes away. Pain
is an important message from your body, and one you must listen to. If you allow pain to progress unattended, you are in for
trouble as it moves toward a chronic condition.
Most RSI victims suffer from one or more forms of chronic
pain, which tend to persist long after the onset of an injury, and
health care providers often mismanage chronic pain. Chronic
pain can be dull one day and sharp another as it moves
throughout the body. The good news is that it can eventually
subside with appropriate treatment. If allowed to persist or
worsen, a vicious cycle ensues, leading to a more complicated
form of pain, complex chronic pain.
Complex chronic pain differs from acute or chronic pain
because it stimulates a part of the nervous system called the limbic system. The limbic system is a group of brain structures
common to all mammals and associated with involuntary nerve
function, behavior, and smell. As RSI progresses, it can induce
complex chronic pain by its effect on the sympathetic nervous
system, over which we have little control. This dysfunction of
the sympathetic nervous system perpetuates pain by beginning a
vicious cycle of blood vessel instability accompanied by the
release of pain-stimulating substances into the bloodstream that
continue uncontrolled. Often it provokes the genesis of new pain
bers. One common sign of complex chronic pain is a cooling of
the hands and forearms, often combined with sweating as the
pain level increases. This is known as reex sympathetic dysfunction. I have found this present in 20 percent of my RSI
patients. When complex chronic pain occurs, treatment is usually more difcult and prolonged because circulatory changes
diminish the blood supply to the soft tissues and delay healing.
Managing Pain
89
Research suggests that this may be an early form of RSD/CRPS

and may be more common than previously thought.
If aggressive and focused treatment is not begun quickly, the
condition can progress to the most serious form of complex
chronic pain, which is reex sympathetic dystrophy (RSD) or
complex regional pain syndrome (CRPS).
One of my patients is a good example of what can happen if
RSD/CRPS is not recognized in time. M. L. is a university professor of literature who traveled from another city to see me.
The use of a computer was an integral part of her work. A few
months earlier, she had begun to notice the onset of pain and
numbness in her right arm. For a month or so before this, she
had spent long hours at her computer keyboard nishing a
book. At rst she felt pain only when working; later the pain
persisted even after work. Finally it became a permanent part of
her life, with worsening symptoms including a burning feeling.
She saw her physician who, perplexed, recommended a second
opinion. The second doctor suggested she stop using her arm,
which had become by this time almost completely useless anyway. Her pain was so acute that she went around with her arm
folded against her body so no one would accidentally touch it.
She also noted that her hand and arm had become cold, and she
could no longer continue her work. Her physician then suggested she wear a splint, which gave her some temporary relief.
But in the long run, the splint compounded her problems. The
immobilization told her brain that now her right extremity was
completely shut down. Blood was shunted from the skin to the
deeper tissues. Calcium was being washed out of the arm and
hand bones, while skin and nail changes were beginning to
become apparent. When I rst saw her, she was in obvious pain,
with her right arm exed at the elbow. Her skin was dry and
cool, except that her palms were sweaty. She complained of
severe pain, which worsened when her skin was lightly touched.
On further examination, I found that she had evidence of neurogenic thoracic outlet syndrome (see chapter 2) and a frozen
right shoulder. I instructed her to discard her splint and begin
moving her arm as much as she could tolerate it. I referred her
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to a physical therapist with a prescription to gradually mobilize

her right arm and shoulder and begin postural retraining. Fortunately, her RSD/CRPS was still amenable to this approach. I
also prescribed Neurontin (gabapentin; see later in this chapter)
for her pain so that the therapist could begin manual work on
her soft tissues. I kept in close contact with her and her physical
therapist, monitoring her progress. It wasnt easy for M. L. to
regain function, and the process took many months. But I was
gratied to see marked improvement on her return visit. She
was lucky after a year to have complete recovery, though I
warned her to continue her mobility and strengthening exercises
to avoid a relapse. Many other patients are not so fortunate.
Another young woman I saw came at a much later stage.
Despite multiple interventions including nerve blocks, massage,
and biofeedback, her RSD/CRPS spread to all her extremities,
resulting in almost complete disability. To add to her woes, she
entered a protracted battle with insurance carriers who seemed
to have little understanding of the seriousness of her problem.
Her prognosis for a return to health was poor.
In 1993, the term complex regional pain syndrome types 1
and 2 was proposed as a substitute for the term RSD by the
International Association for the Study of Pain. Type 1 CRPS is
essentially what we see in people with RSI who develop what
was called RSD. The onset of type 1 CRPS is more closely
related to soft-tissue injury than is type 2, which involves more
severe nerve injury and was formerly called causalgia.
In both types there are four basic signs: Burning pain made
worse by movement; swelling that is persistent and progressive
and sometimes localized; stiffness that is progressive and results
in diminished movement of the joints; and discoloration due to
circulatory changes.
History and a physical examination usually can establish the
diagnosis, especially when there are skin and temperature
changes. The only early diagnostic tests that will produce ndings are thermography or computer-assisted tomography, both
of which are difcult to obtain. The other possible test is a stellate ganglion block, which consists of injecting a local anesthetic
Managing Pain
91
into the grouping of sympathetic nerves in the neck to see if this

provides relief from pain. Yet it is at the early stage of this illness
that aggressive treatment must begin. When the disease has
reached a severe stage, tests such as MRI, EMG, and CT scans
will show involvement of bone and soft tissues. But at this stage,
treatment is far more difcult and less effective.
Treatment of RSD/CRPS
Early diagnosis can produce a good outcome. Begin physical
therapy to maintain exibility, range of motion, and strength.
People with CRPS tend to limit movement because of stiffness
and pain. They should be encouraged to perform range-ofmotion exercises, but too vigorous an exercise program can
cause a are-up of symptoms. Use medications to control symptoms and to block sympathetic nerve overactivity. These include
tricyclic antidepressants and gabapentin (Neurontin), which has
proven to be especially effective. Sometimes other medications
such as beta blockers, clonidine, and carbamazapine have been
used. In more severe cases, nerve blocks may give temporary or
permanent relief.
Make the necessary lifestyle changes, and provide ergonomic
and biomechanical intervention. RSD/CRPS comprises about 10
percent to 20 percent of chronic pain patients. This means that
there are approximately 4 million RSD/CRPS patients in the
United States.
RSD/CRPS is a serious injury that must be recognized early
and treated aggressively. RSD/CRPS can cause severe
migraines, burning pain, swelling, nail changes, and movement
disorders such as tremors and dystonia. It has been known to
migrate to other body partsfor example, it can begin in one
arm and then appear in the other arm or either or both legs.
Any kind of soft-tissue injury, such as an operation causing
nerve damage, or an injury as banal as getting your hand caught
in a door, can lead to the onset of RSD/CRPS of the type 1 or
type 2 variety (also see chapter 2).
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In the RSI patient, the majority of whom have postural

problems (rounded shoulders and head thrust forward), nerve
injury from muscle imbalance combined with overuse of muscles are often enough to transform chronic pain into complex
chronic pain because of sympathetic nervous system involvement. This may ultimately result in RSD/CRPS if treatment is
not begun early enough to prevent it.
Self-Treatment
Learn from your pain, pay attention to your pain, and you
should eventually conquer it. With RSI, rest may be the most
important initial step toward healing. Here, rest is a relative
term. Total rest, such as going to bed and lying there, quickly
causes muscles to atrophy and contract. This is not the right
type of rest. You need relative rest, avoiding anything that would
stress your injured nerves and muscles. This means not only
avoiding or diminishing computer use but also limiting other
activities, such as playing musical instruments, knitting, gardening, cooking, or any upper-body activity that causes distress.
While you may have to continue working to earn your living,
you should take rest breaks, pace yourself, and stretch during
the workday. This means you may have to negotiate with your
supervisor (or yourself) about your work pace. After making
certain ergonomic and biomechanical changes and getting medically evaluated, you are ready to begin working with your
physical or occupational therapist to conquer RSI.
Icing is an immediate and effective way to diminish the level
of pain in RSI. It is most effective if the ice is put in direct contact with the skin for short intervals of forty to sixty seconds. It
should be applied by moving it over painful tissues until the skin
gets slightly numb and reddish. Do this for no more than a
minute at a time and no more than ten times a day. Dont stretch
the iced muscle because muscles tend to gel when cold. Wait at
least fteen minutes before you begin gentle stretching. Do not
use ice until you have consulted with your physician. Do not use
Managing Pain
93
ice if you have reex sympathetic dysfunction or RSD/CRPS, or

if you have circulatory problems, diabetes, Raynauds syndrome, or any other condition where cold might be harmful.
An easy way to apply ice is to ll a paper cup with water and
let it freeze. When it is solid, tear off the lip, place your arm on
a towel and apply it directly to the skin, rubbing back and forth
gently. Place the cup back in the freezer for reuse.
Although it is usually not as effective as ice in relieving pain,
heat can relax soft tissues, even though it doesnt penetrate very
deeply. You can apply heat in a variety of ways, including a heating pad, moist hot packs, and a warm shower. Your therapist can
use ultrasound. Avoid high levels of heat and prolonged application, since these can produce burns and skin mottling or discoloration.
Some treating physicians recommend application of topical
creams and liquids to diminish muscle pain. These are aspirinbased creams, NSAID creams, and creams containing capsaicin.
Capsaicin is a pepper derivative, and its use should be limited to
two days at a time to avoid dermatitis, blistering, and ulceration.
Transcutaneous Electrical Nerve

Stimulator (TENS)
TENS is a noninvasive electrical device that stimulates the
nerve bers that travel to the neocortex of the brain. It is used
for controlling pain at trigger points and is helpful particularly in
the treatment of RSD/CRPS by applying stimulation at multiple
locations.
Acupuncture and Acupressure

Acupuncture is a treatment that involves sticking small needles
into key parts of the body that relate to the symptoms sites.
Acupressure involves applying hand pressure to these sites.
Acupuncture is useful for the treatment of pain driven by an
94
overactive sympathetic nervous system (complex chronic pain)

and works best for that condition by stimulating specic nerve
bers. One of its effects is to activate endorphins, which are the
bodys natural pain suppressors.
Acupuncture is not a very useful treatment for simple
chronic pain because it provides relief that lasts for only a few
hours. Acupuncture is less effective if used as the sole therapy
modality and should be used in conjunction with occupational
and physical therapy. Acupuncture should be performed only by
qualied, experienced practitioners.
Local Injections of Corticosteroids

and Anesthetics
Some physicians, to relieve acute tendinitis or other inammations such as painful trigger points, use local injections of solutions containing steroids or a local anesthetic. These injections
can break the pain cycle and diminish inammation. Steroid
injections should be limited to no more than two or three applications at one site, since they can potentially cause tendon rupture, which could need surgical repair. Steroid injections can
dissolve fatty tissue, leaving unsightly pitted areas in the skin.
In the hands of experienced and competent physicians, these
injections can be helpful. Systemic side effects from corticosteroids can occur, which might include rising blood sugar,
muscle weakness, osteoporosis, or increased susceptibility to
infection.
Iontophoresis and Phonophoresis

Corticosteroids also can be applied in less traumatic ways. Local
areas of inammation can be reduced by applying a 10 percent
hydrocortisone cream to the skin and driving it into the tissues
with an electric current (iontophoresis) or with sound waves
(phonophoresis). This is usually prescribed by a physician but
performed by a physical or occupational therapist.
Managing Pain
95
Splints
The use of splints to control pain is usually a step in the wrong
direction. Most of the injury and pain associated with RSI needs
to heal actively. By this I mean that some gentle movement is
necessary to encourage soft tissues to grow with the lines of
force (proper direction) of the tissue. Immobilizing these tissues
might relieve some of your pain, but splinting will simply
encourage muscle weakness and random, chaotic tissue healing
that will be less functional than the tissue was before the injury.
Furthermore, with splinting, joints become stiff and muscles
atrophy. More seriously, the immobilization of splinting can lead
to, worsen, or predispose you to RSD/CRPS. If you have a broken bone, a splint or a cast is a logical treatment, but when its
removed, the immobilized soft tissues always need to be rehabilitated. Unfortunately, too many physicians and therapists treat
soft-tissue injury as if they were treating a broken bone, which
can prolong the problem.
Many people splint themselves in a misguided attempt to
prevent RSI or to keep it from developing or spreading. Wrist
splints may cause pain to migrate to muscles that have not been
immobilized by the splint. This increases muscle imbalance by
causing atrophy in one group of muscles and overuse in another.
If you are concerned about keeping your wrists straight, dont
do it with a splint. Instead, get a split keyboard, change your
technique, and check the ergonomics of your workstation. See
chapters 7 and 8 for more details.
Occasionally, splinting may be necessary to overcome a
severe, acute inflammation such as the thumb tendinitis of
DeQuervains disease or to get relief from night pain if you
are suffering from carpal tunnel syndrome. If your doctor gives
you splints, ask what the rationale for the treatment is. Always
use splints for the minimum amount of time, and never splint
yourself. Recently a physical therapist I know, competent and
aware of the dangers of splinting, applied a short-term splint
for someone with acute DeQuervains disease. In a week, the
patient developed early signs of RSD/CRPS. Thanks to the
96
awareness and quick action of the therapist, treatment was

started immediately, but it took almost a year for the symptoms
to subside completely.
Mental Splinting
Mental splinting means that you make a knowledgeable attempt
to minimize injury by using proper technique. To do this you
should be at a point in your therapy where you have enough
strength to do this and you are free of pain. Your therapist can
help you by guiding you in proper ergonomics and biomechanics.
Drug Treatment of Acute Pain

Acute pain in RSI usually results from an acute inammatory
reaction of soft tissues to trauma, such as a tendon under tension, (golfers or tennis elbow), a tendon rubbing against its
sheath (DeQuervains disease), or acute low-back syndrome.
Apart from measures such as ergonomic intervention, icing,
rest, stretching, and gentle soft tissue work by a therapist, a number of anti-inflammatory medications are often prescribed.
These should be used cautiously, and under a physicians supervision. Medications to treat acute pain and inammation are a
big business for the pharmaceutical industry, and there are a
large number of products with similar characteristics and risks.
They tend to give limited relief in chronic pain, work better for
acute pain, and often are costly.
Nonsteroidal Anti-inammatory
Medications (NSAIDs)
There are many anti-inammatory and pain relief medications
available either over the counter or by prescription that give a
certain amount of relief of acute pain. Since most RSI patients
suffer from chronic pain, NSAIDs are likely to give only partial
relief.
Managing Pain
97
NSAIDs are the most frequently used medication worldwide. This has led to the realization that the complications of
NSAIDs use, particularly when used on a continuing basis, can
be serious. One of the more dangerous effects is on the gastrointestinal tract, where bleeding and ulceration can occur. The
liver, kidneys, and the cardiovascular system can also be
adversely affected, especially in the elderly. Moreover, not all
NSAIDs have the same toxicity prole. These potential complications have sparked research in a quest for a safer NSAID
derivative.
NSAIDs work by inhibiting the so-called cyclooxygenase
systems (COX). Two main COX systems were found to be
inhibited by NSAIDs. This led to a separation of NSAIDs into
two categoriesconventional and gastroprotective based on
their effect on the COX systems.
Conventional NSAIDs
diclofenac (Voltaren, Cataam)
mefenamic acid (Ponstel)
diunisal (Dolobid)
meloxicam (Mobic)
etodolac (Lodine)
naproxen (Naprosyn, Anaprox, Naprelan)
fenoprofen (Nalfon)
piroxicam (Feldene)
ibuprofen (Motrin, Vicoprofen)
salsalate (Disalcid)
indomethacin (Indocin)
sulindac (Clinoril)
ketoprofen (Orudis, Oruvail)
tolmetin sodium (Tolectin)
ketorolac tromethamine (Toradol, Acular)
The COX-1 system is found mostly in the gastrointestinal

tract and is said to have a protective function, particularly in preventing peptic ulcers and hemorrhage. The COX-2 system is
98
found at the site of an inammatory reaction, where it produces

prostaglandins. Therefore, nding a specic COX-2 inhibitor
would be desirable, since its main effect would be to diminish
inammation and pain without endangering the gastrointestinal
system and kidneys. Two approaches have been developed to
solve the problem. The rationale involves trying to selectively
inhibit COX-2 activity and beneting from its analgesic and
anti-inammatory activity, while allowing the COX-1 system
to carry on its protective function in the gastric mucosa and
kidneys.
Two COX-2 specic inhibitors have been in use since 1998.
They are celecoxib (Celebrex) and rofecoxib (VIOXX). A third
medication, nabumetone (Relafen) may also have high COX-2
capability. Another approach to these potential complications is to
combine a conventional NSAID, diclofenac (Voltaren, Cataam)
with misoprostol (Arthrotec), a drug that increases production of
bicarbonate and mucus and decreases acid production, thus offering protection from bleeding and other complications.
Gastroprotective NSAIDs
celecoxib (Celebrex)
rofecoxib (VIOXX)
nambutone (Relaex)
diclofenac and misoprostol (Arthrotec)
Finally, there is a potential conflict between at least one

NSAIDibuprofen (Advil)and aspirin. Advil diminishes the cardiac-protective effect of aspirin. Also, if you are taking an ACE
inhibitor for high blood pressure, you should avoid NSAIDs.
A severe life-threatening condition known as an anaphylactoid reaction can occur with NSAID and aspirin use. This can
present as an acute allergic reaction preceded by a sense of
uneasiness, agitation, and ushing, then tingling, itching, difculty breathing, convulsions, and shock. Immediate medical care
in such cases is essential.
It should be noted that the whole area of NSAIDs and their
Managing Pain
99
complex relationships with the COX systems is undergoing

further intensive evaluation by researchers. NSAIDs and NSAID
derivatives are useful, but they should be used with great care,
based on the treating physicians decision. Even with gastroprotective NSAIDs there is still some risk of GI bleeding, which can
increase with the simultaneous use of SSRI antidepressant medication.
Aspirin and Other Salicylates

Aspirin is a salicylate that has many actions, including the ability
to reduce pain, fever, and inflammation. Like NSAIDs, it
inhibits COX-1 and COX-2 systems. The risks are similar to
those of NSAIDs, including the potential for allergic reactions.
Aspirin is often compounded with codeine or codeine derivatives to make it a more effective pain medication because
codeine desensitizes the nerves to all pain-stimulating substances, not only prostaglandins. Aspirin can also be applied
locally in the form of a cream. Choline magnesium trisalicylate
(Trisilate) is similar to aspirin in its action. Consult your physician before using any of these medications, and avoid them if
you are pregnant.
Other Pain Medications

Acetaminophen has fewer side effects than aspirin, although it
should not be taken with heavy alcohol use. It is often combined
with codeine to block the pain-producing substances linked to
RSI. It is a weak nonselective inhibitor of COX-1 and COX-2.
It is not an NSAID, and it has a low incidence of gastrointestinal
complications. It provides pain relief but has no anti-inammatory effect. There are various brands of acetaminophen, but
there is little if any difference among them.
Muscle Relaxants
There is a group of medications whose purpose is to relieve
muscle spasm. They also provide analgesia, which in some cases
100
may be better than aspirin or acetaminophen. Side effects may

include headache, diarrhea, drowsiness, and dry mouth.
Muscle Relaxants
chlorzoxazone (Paraex, Parafon Forte, Remular-S)
carisoprodol (Soma)
cyclobenzaprine HCL (Flexeril)
methocarbamol (Robaxin)
orphenadrine citrate (Norex, Norgesic)
Orphenadrine citrate is prescribed to relieve mild to moderate musculoskeletal pain. It should be avoided if you have glaucoma, bladder or prostate problems, or an allergy to aspirin.
Norex is sometimes prescribed as a muscle relaxant. These
medications, while useful, have many potential side effects and
should only be taken after careful assessment of your ability to
tolerate them safely.
The Antidepressants Role in

Pain Management
Recent investigations in sports medicine have shown that after
an injury, athletes often suffer a period of depression. Depression and anxiety are common parts of RSI. Aside from treating
depression, antidepressants raise the pain threshold and are
often used in conjunction with NSAIDs and physical therapy to
control pain. The two main classes of antidepressants used in
pain management are the tricyclics and the selective serotonin
reuptake inhibitors (SSRIs). The tricyclics are particularly useful
in controlling complex chronic pain.
The tricyclic group includes medications such as amitryptyline and nortriptyline HCL (Aventyl) and desipramine (Norpramin). The tricyclics are used for chronic pain management in
RSI, although they have many side effects and interact with a
number of other substances, including monoamine oxidase
inhibitors, yet another class of drugs used in the treatment of
Managing Pain
101
depression. These side effects include cardiac arrhythmias, postural hypotension (a drop in blood pressure when moving from
a sitting to a standing position), sedation (drowsiness,) dry
mouth, constipation, confusion, and urinary retention. Tricyclics
relieve pain through serotonin and norepinephrine reuptake
blockade as well as blockade of alpha receptors and sodium
channels. (See the glossary.) Tricyclic antidepressants are the rst
line in the medicinal treatment of RSD/CRPS.
The selective serotonin reuptake inhibitors are a newer group
of antidepressants, and include uoxetine HCL (Prozac), sertraline HCL (Zoloft), paroxetine HCL (Paxil), and citalopram
(Celexa). They are sometimes used with NSAIDs because they
raise the pain threshold, but they are not as effective as tricyclics
in the management of chronic pain. Unrelated chemically to tricyclics, these antidepressants block central nervous system uptake
of serotonin. They are also used to treat anxiety, panic disorder,
and obsessive-compulsive disorder. These medications to control
pain and depression should only be taken under the direction of a
psychiatrist who specializes in psychopharmacology.
Recently there has been some concern about the nding that
SSRIs can increase the risk of gastrointestinal bleeding. The relative risk has been described as being about three times higher
than in persons not on SSRIs. Although the absolute risk is
small, it is increased if patients are on NSAIDs or aspirin.
Apparently SSRIs inhibit the uptake of platelet serotonin, weakening the bloods ability to clot.
Gabapentin (Neurontin)
Recently this second-generation antiepilepsy drug has been
found promising as a medication to control neuropathic pain
associated with RSI and several other conditions, including
RSD/CRPS. The way gabapentin works is not fully understood, but it is distinct from the way that the tricyclics and SSRIs
work and is proving to be a very useful medication because it is
well tolerated with few side effects. It is, however, expensive.
For many persons undergoing the initial stages of treatment
102
who cannot tolerate soft-tissue work, Neurontin is useful to

diminish pain and allow the therapist to perform necessary
deep-tissue work. The dosage of Neurontin will vary according
to what your physician feels is optimal. High doses may be necessary in some people to get an optimal therapeutic effect. Side
effects include sleepiness and dizziness. As with any other of
these medications, Neurontin should be used only if necessary
and for as short a time as possible.
Carbamazepine (Tegretol, Carbetrol)

Carbamazepine is an anticonvulsant and specic analgesic used
to treat trigeminal neuralgia (a painful inammation of a nerve
in the face). It is sometimes used in the treatment of RSD/CRPS
in combination with physical therapy. However, there are other
medications, such as gabapentin, that produce the same results
with fewer side effects. Its mechanism of action is unclear.
Agranulocytosis, a serious blood disorder, has been reported
with Tegretol, which should be used with care.
Clonidine (Catapres) and

Tizanidine (Zanaex)
These are both adrenergic antagonists. Clonidine is generally
used for the treatment of high blood pressure. Because it acts on
the central nervous system to reduce sympathetic nerve activity,
it has been used in the treatment of RSD/CRPS.
Tizanidine is useful in the treatment of headache and neuropathic pain. These drugs should be carefully titrated. Side effects
include sedation, hypotension, and dry mouth.
Propanolol (Inderal)
Propanolol is a beta adrenergic receptor blocking agent used in
the treatment of hypertension and cardiovascular disease. It
diminishes sympathetic nerve effect and has been used in the
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103
treatment of RSD/CRPS. Tricyclics, serotonin reuptake

inhibitors, and gabapentin (Neurontin) are now more likely to
be the drugs of choice. Propanolol is sometimes prescribed for
performers and speakers to control performance anxiety or
stage fright.
Opioid-Based Medications
The most useful of these are codeine, oxycodone, and
propoxyphene napsylate (Darvocet, Darvon-N, and Propacet,
respectively). Usually these medications are combined with
NSAIDs or aspirin to produce a greater benecial effect than
each would do alone. The opioids can counteract most of the
pain-stimulating substances released from injured tissues. Opioids have limited long-term use because of signicant side effects
such as dizziness, nausea, constipation, the need for increasing
doses over time, and the possibility of habituation. Habituation
is less likely if severe pain is present and sustained. Opioids
relieve pain through activation of a number of specic receptors
found in both the central and peripheral nervous systems.
Oxycontin
Special attention should be focused on a form of oxycodone
called Oxycontin. Recently, the potential for abuse and fatal
overdose has been reported. Since this is a slow-release tablet, it
should be swallowed whole, and not broken or crushed, which
causes a sudden release that can be fatal. This drug should be
used only in people who are opioid-tolerant. There is little if any
indication to use this medication in RSI.
Chondroitin Sulfate and Glucosamine

Recently, a combination of chondroitin sulfate and glucosamine
has received attention as a medication for treating arthritis,
rebuilding cartilage, and diminishing pain indirectly. Although
104
many people nd it helpful, reliable scientic proof of its efcacy

is not yet available. Studies are being conducted to determine its
usefulness.
Physical Therapy, Occupational

Therapy, and Home Exercises
Stretching, strengthening, postural exercises, and soft-tissue
work under the guidance of your therapist are the front-line
defenses against pain and ultimately the bases for healing and
resolution of RSI. The supply system for these defenses is your
conscientious attention to your home program, so that, without
backsliding, progress is made each time you see a therapist. The
team approach to treatment cant be overemphasized. In some
cases, additional therapeutic modalities can augment your treatment teams work but should not substitute for it.
6
Your Lower
Back
Our torments may also in length of time become our

elements.
John Milton (16081674), Paradise Lost
Good posture is essential in preventing repetitive strain injury,

and your lower back is the foundation on which the many other
elements of posture are built. If you sit at your computer for
long periods of time, you may think you are not doing much
physical work. Yet the muscles of your lower back are hard at
work maintaining you in this seated position. The kind of physical work your muscles are doing is dened as static loading,
where the muscles act as braces for your frame. Static loading
also forces these muscles to work with less nourishment in the
form of blood supply, and therefore they are more vulnerable to
fatigue. This is more likely to occur if you are poorly conditioned, or if you assume awkward postures as a result of poor
workstation equipment or arrangement.
It is estimated that 50 to 80 percent of people in developed
countries suffer from lower back pain. Next to upper body RSI,
low back syndrome is the most frequent work-related problem
reported to employers as a cause of disability.
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106
Your occupation may not be the only reason you incur low
back pain. As in upper body repetitive strain, there are many
possible causes, and this creates confusion. Some of the risk factors relate to what you do and how you do it at home. Other elements of your lifestyle, such as the sports you engage in, your
physical condition, and your diet can also become risk factors.
Things not necessarily under your control, such as your hereditary makeup, your age, your sex, or an underlying illness play a
role as well. Static or awkward posture, anxiety, mental stress,
depression, and job dissatisfaction are all strong risk factors.
Because of its sheer number of victims, lower back pain has
become a serious socioeconomic problem, costing industry and
the health care system billions of dollars annually. In the United
States, approximately $14 billion a year are spent dealing with
the results of lower back pain. To put it in personal terms, every
adult has an episode of low back pain at least three times in his
or her life.
Our bipedal posture places great vertical and lateral pressure
on the spine. This can result in two common injuries. The rst,
spondylolysis, accounts for 6 percent of low back pain. This
condition results from a defect in function of the superior and
inferior articular processes (see chapter 1), usually of the fourth
and fth lumbar vertebrae. As much as 50 percent of athletes
with low back pain may be suffering from spondylolysis.
Another mechanical condition that might occur is called
spondylolisthesis. Here, there is slippage of the body of the vertebra above another vertebra. This typically occurs as a result of
degenerative changes in the spinerheumatoid arthritis or
osteoarthritis, for example.
Dening Low Back Pain

Low back pain exists under a number of different names: lumbago, painful lumbar syndrome, lumbosacral strain, or sciatica if
the sciatic nerve root is involved. If acute pain persists for twelve
weeks or more, it can be considered chronic.
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107
Apart from bony involvement by deterioration or slippage of

spinal elements, pain in the lower back is usually the pain of
muscle spasm, where nerve bers are irritated by a tightened
muscle. There is associated stiffness and increased pain on certain movements. This pain usually has no recognizable pathologyyou rarely find an infection, a fracture, or a tumor.
Fortunately, 90 percent of people recover from acute low back
pain in about six weeks. Between 2 and 7 percent of those with
acute low back pain evolve into chronic pain. Recurrent pain
attacks account for the majority of absenteeism from work.
In upper body RSI, we know that the pain is subjectiveyou
are the only one who can experience it and discern its characteristics and intensity. This can create problems for patients,
since the examining physician may not understand or believe
what the victim is experiencing. This is when many people are
told that its all in your mind. The same is true for low back
pain. The subjective nature of the pain may also make it difcult
to treat. Objective evidence can often be elicited by applying
pressure to the painful area and noting the sudden reaction of
the patienthe or she might exclaim, jump, or whine.
Poor work habits are generally the main cause of low back
pain. Specically, about 70 percent of the pain is associated with
sudden or heavy lifting, usually done improperly with the legs
extended instead of bent. Pushing or pulling can account for
another 10 to 15 percent of injury. Dont consider yourself
immune just because your work doesnt usually include these
activities. If you are in poor general condition, inadvertent lifting
or pushing (even just reaching for the ling cabinet) can set off
an acute episode. Simply sitting at your workstation can place
substantial demands on your lower back. Other activities you
may not even realize put you at risk may bring on an episode:
jogging, aerobics, tennis, golf. Even eating to excess can cause
you to gain weight that places an extra burden not only on the
spine, but on the hips and knees as well. If you are a musician
playing the cello or other instrument while sitting, you are at
risk. If your instrument is played standing, you may also be at
risk. Ive treated numerous percussion and bass players whose
108
low back static tension led to their problems. Sometimes the

cause of these events can be extremely difcult to detect. As an
examining physician, a thorough history and physical examination or even a biomechanical and ergonomic analysis may be the
kind of detective work needed.
X-rays and MRIs are usually ordered by the examining
physician, who must avoid the trap of considering any single
nding as the cause of the problem. Many people with abnormal
X-rays may have no symptoms at all. In fact, about 85 percent
of people will have no discernible nding. About 4 percent of the
time, compression fractures related to falls and osteoporosis are
found, while about 1 percent are found to have spinal tumors.
Treatment of Acute
Low Back Pain
Acute low back pain may be treated differently from the chronic
variety. Acute low back pain is essentially a self-limiting disease.
In the past, bed rest was a treatment mainstay, easily accepted by
patients for the obvious reason that it affords immediate relief. It
is now recognized, however, that continued activity is not harmful, and is in fact the best way to promote healing. Bed rest can
be harmful in that it can stiffen or weaken muscles that need to
be mobilized and used. During the acute period, NSAIDs (see
chapter 5) can be useful to control pain and facilitate activity.
Muscle relaxants can also be helpful, but they have side effects
including sleepiness and habituation potential for some. Behavioral therapy that consists of working with a professional to
resolve issues such as anxiety and fear can also help. Ergonomic
and biomechanical interventions are appropriate as well during
this stage.
On the other hand, there are approaches that may have minimal or doubtful effectiveness. Often these approaches may not
be harmful in themselves, but they may not be cost-effective.
These include the use of certain strong analgesics such as opioids, antidepressants, colchicine (a drug used for its anti-inam-
Your Lower Back
109
matory effects), steroid injections, facet joint injections, trigger

point injections, biofeedback, massage, traction, spinal manipulation, acupuncture, and lumbar supports. The decision to use
one or more of these approaches should be made in consultation
with your physician or physical therapist, since some might be
helpful in specic cases.
Treatment of Chronic
Low Back Pain
In chronic cases, exercise therapy becomes a cornerstone of
treatment, which should include strengthening the often forgotten abdominals. Changing the working milieu with ergonomic
and biomechanical interventions is useful. Likely to be benecial
are behavioral therapy, the use of NSAIDs and analgesics, trigger point injections, and attending a back school. Back schools
programs usually administered by the physiatry department of a
hospital or a back pain centerteach you both preventive and
treatment aspects of low back pain. The knowledge gained can
be extremely helpful in improving conditions. There is less unanimity about certain other measures, but they may be useful in
specic cases. These include using antidepressants and muscle
relaxants, epidural steroid injections, and lumbar supports.
Transcutaneous electrical nerve stimulation (TENS) to block
pain messages, spinal manipulation, and acupuncture are also
sometimes used. Two approaches that are either ineffective or
harmful are facet joint injections and traction.
Surgery for Back Pain

Surgery for back pain is a mineeld of controversy. Of course, if
diagnostic tests reveal the presence of a specic lesion, such as a
tumor, or if there is a progressive neurological decit, surgery
may be the solution. But in the absence of such ndings, surgery
can be a problem. Immobilizing spinal segments may possibly
110
relieve some of the pain, but it can also upset the delicate
dynamic of the spinal column. Still, some people are willing to
accept less function for relief from pain. If surgery is contemplated, seek at least a second opinion and look for a physician
who has experience with low back surgery. Often the decision
about what kind of physician should do this surgery comes up,
since both orthopedic surgeons and neurosurgeons may be
adept at it.
Low back pain is a common, and often neglected, component of the diagnosis and treatment of RSI. Simply understanding the reasons for its onset and the possible treatments can be
helpful in obtaining relief.
7
Physical and Occupational
Therapy for RSI
I bend and I break not.

Jean de la Fontaine (16211695)
Physical and occupational therapy are the keystones of care in

repetitive strain injury. Once you have been diagnosed with
RSI, the treatment portion of your therapy should begin. To
regain what you have lost in normal body function, you must
concentrate on your body. This means total attention to your
therapists instructions and your home program. Anything less
prolongs your pain and your other symptoms. In most cases,
treatment must begin gradually to avoid relapse. This is where
your therapist becomes indispensable.
A common mistake at the beginning of therapy is to overdo it.
Another is the false belief that without pain there is no gain. In
RSI, pain should never be used as a guide to exercise progression.
You must rely on your own awareness. Relying on the therapist to
carry the workload of your recovery means that you will not
recover. Your home program is what maintains your therapists
mobilization effort while taking you to your next level of progress.
And once you are better, you will maintain that condition only if
you change your exercise habits permanently. Getting back to
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112
work requires constant vigilance in your exercise program. You

can never return to indolence if you want to stay healthy.
The Right Therapy with the

Right Therapist
You wont recover from RSI unless you work hard at it. There is
no quick x or easy way out. This means participating in a program of exercises and other treatments under the guidance of your
physician and your physical or occupational therapist. This chapter describes both basic and advanced exercises and stretches,
most of which you can do at home, at work, and in the gym on a
regular basis with the periodic supervision of your therapist. This
sounds easy enough, but it is a major challenge to nd not only
the right physician (see chapter 2) but the right therapist as well.
Finding Treatment
The person in charge of your therapy should be a certied physical or occupational therapist with a bona de interest in RSI.
This is not a job for the trainer at your gym. Find out whether
the facility youre considering is a busy oneyour therapist will
need to spend a lot of personal time with you. Visit the facility
and note how much time the therapist spends with each client.
Beware of the therapist who insists on the immediate use of
weight training. Premature use of weights will only add to your
symptoms, and this is one of the principal reasons why patients
abandon treatment. You should not be using weights for forearm
and wrist exercises when you start treatment, but only after healing has begun and your forearm and wrist pains have diminished. If your therapist doesnt understand this principle, nd
someone who does. Poor management by the therapist can
make you cynical about therapy and delay your recovery, and
rotating therapists is not the best approach. You need to develop
Physical and Occupational Therapy for RSI
113
a relationship with one supervising therapist; any substitute

should be part of your primary therapists team.
Personal Trainers
Personal trainers who often work in gyms are not qualied to
treat RSI. In a recent study done at Lehman College in New
York City, a survey of 247 trainers revealed that 20 percent of
them had no certication whatsoever. Trainers may be ne for
the healthy, and many trainers are quite knowledgeable. But RSI
is a serious medical condition. Trainers should not be considered
a substitute for your physical or occupational therapist. Once
your condition improves, a competent trainer could work with
your therapist to continue your ongoing maintenance program.
Fight for Therapy Coverage

Unfortunately, managed care, workers compensation, and
restricted insurance reimbursement have curtailed benets for
physical and occupational therapy. This therapy is important,
and you should go to great lengths to secure your coverage benets. Do not accept rejection of therapy claims without battling
for what is a necessary and vital part of your treatment. Often,
your insurance provider just does not understand RSI. Enlist
your physician, therapist, benets manager, and anyone else
who can help you document your needs. Dont give up!
Why You Need Your

Exercise Program
Proper exercise is as critical to you as it is to a professional
athlete. If you are recovering from RSI injury without active
participation in home or gym exercises, you are not likely to get
114
completely better. The same holds true if you want to prevent

RSI. A physician and physical or occupational therapist working
together is the best approach to your exercise program. Too
much exercise or inappropriate exercise may increase pain or
aggravate symptoms. Too little exercise could impede the
progress of treatment.
A regular exercise program is important if you want to get rid
of the pain, numbness, tingling, and disability of the disorder.
Remember: you are an upper body athlete. Any athlete needs
training to use his or her body. None of the following exercises
should be done without a physical examination by a physician,
who should provide a prescription for the therapist based on your
examination ndings. These exercises are a guide for your therapist and must be supervised by him or her. Self-programming
your exercise regimen could lead to injury, which could undermine your will to continue this essential part of your therapy.
The RSI Exercise Program

Warm-ups
Warm-ups are a critical prelude to your exercise program. Warmups enhance circulation and mobilization of the soft tissues, maximizing the benets of the rest of your exercise program.
Wall angels
No gym equipment is necessary here. Wall angels, which can be
done against a wall or on the oor, mobilize the joints of the
upper back, shoulders, and neck, increasing mobility and circulation. Any at wall surface or oor area will do. The legs should
be held slightly apart, the knees bent, and the back and arms at
against the wall or oor. The abdomen should be tucked in
slightly. As you move your arms up and down, you will feel the
shoulder blades moving and loosening, without the use of your
upper trapezius muscles (between the neck and the shoulder).
This exercise is harder to do than it looks, but gradually will
115
Done against the wall or

lying on the oor, this
warm-up exercise is also
excellent for correcting
posture.
become easier as your posture improves. Start with one or two

sets of ve wall angels two or three times daily, adding sets based
on the advice of your therapist.
The UBE (Upper Body Ergometer)
This device is available in some gyms. If you are lucky enough
to have access to one, it is an excellent upper body warm-up
device. Properly used, the UBE will exercise the large trunk
muscles instead of the smaller forearm muscles. The shoulder
The UBE is a good

warm-up apparatus that
later can also promote
upper back and shoulder
mobility and strength.
116
joint should be lined up with the axis of the crank of the UBE.
Resistance is set at a minimum level, and the handles are held
loosely. Use of the UBE should be under the counsel of your
therapist to determine time limits and to avoid the possibility of
further injury. You should have assistance in tting the UBE for
your proportions prior to use, and you should memorize these
settings for the future.
Bodyblade
This is a device you can purchase for home use, since it is
generally not available in gyms. It comes in two sizes. Start with
the smaller length. Basically, Bodyblade is a exible bow with a
handle in the middle that makes the blade oscillate when you
shake it. Initially, you use Bodyblade by shaking it and changing
direction frequently, which encourages natural muscle function.
It is not as easy to master as it appears, and injured persons
should start with thirty seconds of use, building up to three to
six minutes with the supervision of the therapist.
Bodyblade is also a good warm-up device that subsequently can be used to strengthen
upper body muscles.
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General Body Warm-up

Bicycle Warm-up
The stationary bicycle can substitute as a warm-up device,
improving circulation in the entire body. Virtually all gyms have
them; you may even have one at home. Holding the handlebars
tightly while doing the warm-ups should be avoided because
gripping the bars could cause a are-up of your injury. Stationary bikes with wide seats are easier to pedal without holding the
handlebars. Since you use only the lower body in this exercise,
beginners have greater tolerance to this warm-up.
Running and Walking
Slow running and walking are excellent total body warm-up exercises. Your arms should be slightly flexed at chest level
and moved while you walk or run, to mobilize your shoulders.
Some people have difculty with this exercise because they cannot
tolerate the strain on their arms. Seek the guidance of your therapist regarding this warm-up; it may not be the best one for you.
Stretches
Stretching the soft tissues prepares them for mobilization and
strengthening. Stretching can improve muscle balance and
diminish the pressure on nerves, joints, and other structures.
Stretching should be done regularly and become an integral part
of your treatment or prevention program. A stretch should be
held for a minimum of thirty seconds to be effective.
Before beginning your stretches the guidance of your physician or therapist is essential to determine which of your joints are
hypermobile and which are tight. The hypermobile joints should
not be overstretched, since this could cause a reactive muscle
tightness or spasm. Wrist stretches are necessary for tightened
forearm muscles in people with RSI. Conditions such as carpal
tunnel syndrome can improve slowly if stretching and soft-tissue
work by your therapist are combined. Stretching should be done
twice a day or more. Stretching during your rest breaks can lead
to a regular routine that becomes a good habit.
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Trapezius and scalene

stretches
It is very important to consult your physician about neck
stretches. While most of the patients I have seen have neurogenic thoracic outlet syndrome accompanied by tightened neck
muscles, a small percentage have protruding discs in the neck.
This is a condition known as cervical radiculopathy, and
stretching might aggravate it, so consult your physician before
you decide to embark on neck
stretches.
To stretch trapezius and scalene muscles, gently tuck your
chin in toward your chest and
depress the shoulder opposite to
the one you are stretching. Placing the arm on the side being
stretched behind your back
helps to depress the shoulder on
that side. Look straight ahead This important stretching exercise conbefore beginning the stretch, ditions the neck, back, and shoulder
muscles, preparing them for strengthenand dont force the stretch by ing and relieving pressure on nerves in
the neck.
pushing hard on your head.
Wrist exor stretches
These can be performed many times a day, especially during
rest breaks. If you are double-jointed at the elbow, perform the
flexor stretch with the
elbow flexed to ninety
degrees. Push with the
other hand on the palm,
not on the ngers.
It is important to stretch the forearm

exor muscles as shown. If you are
double-jointed at the elbow, perform
this stretch with the elbow at a
ninety-degree angle.
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Wrist extensor stretches

Wrist extensor stretches are performed with the arm extended.
Keep the shoulder down on the side you are stretching.
Stretching the forearm

extensor muscle
Physioball/Resist-a-ball exercises
Most gyms have inatable balls of various sizes that can be helpful for stretching certain difcult-to-get-at muscle groups. It is
probably best to start with the largest size. The illustration
below shows the ball being used to stretch the spine while sidelying. You may lie with your back arching over the ball to
stretch your spine and abdominal muscles. For lower trapezius
development and improvement of range of motion, lie face
down on the ball and perform swimming strokes. There are
other focused stretches to get at certain muscle groups that can
be done with the ball; speak to your therapist about them. The
ball should be used under the supervision of your therapist, who
also can tell you what size ball you should use.
The air-lled heavy plastic ball is very useful for stretching the spinal column muscles.
120
Other stretches
There are many beneficial stretches, particularly those that
increase spinal mobility. These should not be performed without
consulting your physician or therapist.
Strengthening Exercises
After your initial evaluation, strengthening exercises usually
begin with two sets of ten exercises, twice a day. These exercises
should be tailored to your needs. At the beginning of strengthening exercises, do not use any weights. If soreness is experienced after exercises but does not continue into the next day,
you may safely continue, but if soreness lasts into the following
day, your exercises were too intense. In that case you should
back off to one set of exercises twice daily.
Weights should be added to your program with caution, as
they can cause injury if you are not prepared to tolerate them,
and they should not be used until you can tolerate two sets of
exercises twice a day. Weights should never be increased by
more than half a pound per week.
If you have pain at rest in your hands or forearms, start with
a cuff weight, not a dumbbell weight. There are cuff weights
with pockets that take metal rods so you can gradually increase
the weight. As pain decreases, switch to dumbbells, holding
them lightly rather than gripping them.
Pain is a signal not to be ignored.
Muscle soreness or a sense of weakness (not pain) indicates
that you are approaching your limit. With the guidance of your
therapist, a few more repetitions beyond this sensation of weakness may help you to move to a higher level of effort.
Make sure your therapist is documenting your progress.
This should include an RSI log that documents both your
progress and pain severity (using a 110 scale) This is easy to do
with your therapists help.
The principles outlined above can also be applied to activities of daily living at home, which are discussed in chapter 10.
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For example, if pain from any home activity carries over to the
next day, you are doing too much. Back off.
The Basic 5
These exercises can help you begin the process of healing.
For side-lying exercises you can use a pillow under your arm
or trunk to elevate your body and decrease pressure on your
shoulder.
Punching the ceiling
(superior serratus
anterior muscle)
Lying flat on your back, raise
both arms toward the ceiling.
Hold for three seconds. Lower
each arm slowly and avoid elevating your shoulders. Attempt
to do them twice a day, ten repetitions, advancing to multiple sets
of ten. If pain continues to the
next day, discontinue and discuss
with your therapist.
The punching the ceiling exercise

should be started without weights.
Side-lying whole arm raises (perform on both sides)

Lie on your side, with the top arm elbow extended. Raise and
lower the arm so the palm touches the oor. If this maneuver
causes increased irritation in the elbow, try lowering the arm
only halfway. Attempt
these twice a day, ten
repetitions, advancing
to multiple sets of ten.
If pain continues to the
next day, discontinue
and discuss with your
therapist.
Side-lying arm raises should be done on both sides.
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Side-lying external rotation

Lying on your side with the top arm along the edge of your
body and with your elbow exed to ninety degrees, rotate the
shoulder in a continuous circular motion. Dont rotate too far,
especially if you are hypermobile. Attempt twice a day, ten repetitions, advancing
to multiple sets of
ten. If pain continues to the next day,
discontinue and
discuss with your
therapist.
Side-lying external rotation
Hold up or prone scapula retraction

Lie prone (face down) with one or two pillows under your
chest and a rolled towel under the forehead to allow space for
breathing. Position your arms straight out, and bend your
elbows to ninety degrees.
Now lift your arms off the
oor, squeezing the shoulder
blades together. Hold this
position for three seconds
and lower the arms slowly.
Attempt to do them twice a
day, ten repetitions, advancing to multiple sets of ten. If
pain continues to the next
day, discontinue and discuss
Holdups are a difcult exercise, and weight can be
added as tolerated.
with your therapist.
V exercises (Sitting or
Standing Shoulder Abduction)
This exercise is best performed in front of a mirror. Sit or stand
with both arms close to your body, positioning them slightly for-
ward of your chest. Then bring

the extended arms up 35 to 45
degrees while contracting only the
deltoids (upper arm muscles).
Try not to activate the upper
trapezius (muscles between your
neck and shoulder) too soon so
that neck soreness is avoided.
Attempt to do them twice a day,
ten repetitions, advancing to multiple sets of ten. If pain continues
to the next day, discontinue and
discuss with your therapist.
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The V exercise
Advanced Strengthening Exercises

Advanced exercises can be incorporated into your treatment
program after you have mastered the basic ve and you feel
comfortable with the strengthening program. It is particularly
important to perform these exercises under the supervision of
your physical or occupational therapist. Progressing through
these exercises will strengthen specic muscle groups that are
weak and out of balance as a result of RSI. In some cases you
may need special equipment more
likely to be found in a gym. Again,
these exercises should be carried out
in sets of ten, advancing to multiple
sets of ten.
Latissimus dorsi pull-downs
Latissimus dorsi pull-downs are important to develop synchronous shoulder

and arm movement as well as strength.
The latissimus dorsi muscle, a large

triangular muscle in the back, plays
a major role in shoulder and arm
movement. It extends, rotates, and
moves the arm toward the body and
draws the shoulder down and back.
Most gyms have a bar attached to a
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cable and pulley. Face this machine with elbows extended and
wrists neutral. Dont grip the bar tightly, and pull down, feeling
both latissimus dorsi and abdominal contractions.
Wall push-ups
This exercise stretches, strengthens, and mobilizes front and
back upper body muscles. By
loosening these tight muscles,
pressure is taken off the nerves
and blood vessels supplying the
arms and hands. Stand, placing
your arms above your head and
maintaining straight wrists, with
your feet a bit out from the wall.
Bend your elbows as your chest
leans into the wall. This exercise
also can be done in a corner.
Wall push-ups stretch, strengthen, and

mobilize front and back upper body
muscles.
Abdominal exercises
These exercises are important for muscle balance and posture.
RSI patients should avoid lifting the head off the oor because it
irritates the cervical spine. Do this lying down, with your back
at on the oor. Bend the knees, and alternate toe tapping from
one foot to the other.
Abdominal exercises are necessary for developing muscle balance and power.
These are a critical component of lower back strengthening.
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Wrist curls
These exercises will strengthen
forearm extension and exion.
They should only be started
when stretching and basic
exercises have eliminated pain.
Weights should start at one
pound or less, reaching a maximum of four pounds for the
forearm flexors and three
pounds for the extensors.
Wrist curls will strengthen forearms. Dont

use weights until stretching and basic
exercises have eliminated pain.
Supinator pronator exercises

I have found these exercises useful for those with golfers or tennis elbows. By stretching and strengthening these muscles, pressure is taken off the insertion of the muscles into bone at the
elbow. A hammer can be used for this exercise. Start by holding
it closest to the hammers head; work down the handle as you
progress. With the elbow at your side exed to ninety degrees, a
two-pound weight is rotated back and forth, working both
supinator and pronator muscles.
Supinator curl
Pronator curl
Supinator and pronator curls stretch and strengthen forearms and help to relieve medial
and lateral epicondylitis. Weight should be added as tolerated. Elbow should be exed to
ninety degrees.
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Shoulder shrugs
As an advanced exercise,
begin with two-pound
weights in each hand and
progress according to the
recommendation of your
therapist.
Shoulder shrugs help to loosen tightened

shoulder muscles.
Hand intrinsics with putty

The intrinsic muscles of the hand tend to weaken as a result of
compromised nerve supply. Using various grades of a special
soft putty can strengthen them. Opposing each nger to the
thumb, one at a time, squeeze the putty between the nger and
the thumb. Do the same between each nger and the adjacent
nger in a scissorslike motion. Do ten repetitions per nger.
Different colors of a
special putty provide
variable resistance.
Many other exercises can be incorporated into your treatment

program by your therapist that will relate to your particular
injuries and your progress.
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Manual Therapy: Soft-Tissue

Work for RSI
Your therapist may use the terms soft tissue work, manual therapy, or myofascial release. By whatever name, this is the technique that therapists use to mobilize particularly tight muscles in
the early stages of RSI treatment, when it is difcult for you to
mobilize your soft tissues so you can do your exercises properly.
Manual therapy is an important and helpful adjunct to both
physical and occupational therapy. Not all therapists are skilled
in manual therapy techniques.
The purpose of myofascial release is to locate tightened
muscle groups that impinge on nerves, diminish circulation, and
restrict mobility. In RSI it involves several levels of activity,
which consist of passive stretching by placing thumb or hand
pressure on muscles and tendons to produce tension. By applying tension, the therapist passively stretches muscle that, if you
attempted to actively stretch yourself, would place too much
pressure on the tendons and joints. Active limb movement is the
other part of soft-tissue work. While the therapist maintains
pressure near these tight areas, the patient actively moves the
muscles involved.
For RSI patients, the areas that most commonly benet
from manual therapy include the muscles of the palm, forearm,
pectoralis minor and major, scalene, upper trapezius, subscapularis, latissimus dorsi, and scapula. There are also many painful
trigger points in the upper and lower back that might need manual therapy.*
*Many of the therapies and exercises proposed in this section were developed
in conjunction with Lisa Sattler, M.S., P.T., a physical therapist who specializes in the treatment of RSI.
128
Other Treatment Techniques

There are adjuvant therapies that can be helpful but that should
not be your principal treatment for RSI. These include:
Yoga
Yoga can be used as a relaxation technique and is good for channeling stress. Obviously you want to stick to beginner-level positions and avoid any pose that will strain the damaged muscles of
your body.
Alexander Technique
F. M. Alexander (18691955) was an Australian actor who
developed laryngitis while performing. He observed himself
while speaking and noted that muscular tension was related to
his problem. The technique teaches you to use your muscles
appropriately, with the proper amount of exertion for each task.
The Alexander technique is useful if there is intrinsic muscle balance and an equality of muscle strength. Therefore, physical
therapy and strengthening exercises must be at a level of competence to allow you to benet from the Alexander technique.
You cannot balance your body without strength.
Feldenkrais Method
This method is named after its originator, Dr. Moshe
Feldenkrais (19041984), a Russian-born physicist, judo expert,
mechanical engineer, and educator. The Feldenkrais method is
essentially based on physics and biomechanics. It attempts to
expand self-image through movement sequences. As in the
Alexander technique, it should not be a primary therapy.
Rolng
This is named after Dr. Ida P. Rolf, who started her work more
than fty years ago. Her program is based on a holistic system
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of movement education coupled with soft-tissue manipulation.

The goal is to make more efcient use of muscles, conserve
energy, relieve stress, and diminish pain.
Hellerwork
Hellerwork is named after its originator, Joseph Heller. It is a
system of somatic education and structural bodywork based on
the inseparability of body, mind, and spirit. It is presented as an
eleven-session series whose goal is to release muscle and connective tissue, using deep tissue bodywork techniques. It is
based on the assumption that all people are innately healthy.
8
Ergonomics: Making Your
Equipment Fit
It is unlikely that ergonomics will become redundant in

the ofce of the information age. In general, experience
has shown that with increasing productivity the intensity
of human work increases. The load on the sensory organs
and mental functions, environmental problems and constrained postures are likely to remain challenges for
ergonomics in the future, too.
tienne Grandjean, Ergonomics in Computerized Ofces, 1987
Would you intentionally buy a suit that doesnt t or run a

marathon in one-size-ts-all shoes? Ergonomics is the science
of making sure that things tthat tools, keyboards, musical
instruments, and a host of things we use in our daily lives dont
harm us.
Dr. Carl Zenz, a professor of medicine at the Medical College of Wisconsin, denes ergonomics as a combination of three
things: engineering and physical sciences, behavioral sciences,
and biological sciences. Here we look at the engineering and
physical sciences part of ergonomics so you can view your work
setup from a new perspective.
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132
Ergonomics at the Worksite

Ergonomics should be the responsibility of a specialist trained to
choose and t equipment so that each employee gets the right
equipment and the right training to use that equipment. A major
role for the ergonomist is to keep up with new developments in
safety and design and to advise the employer when equipment
becomes obsolete or dangerous or when employees are experiencing difculty or injury at work.
If there is no staff ergonomist, or if you work at home, making the choice of good equipment becomes your job. New
chairs, desks, trays, keyboards, input devices such as the mouse,
track ball, joystick, and touch pad come on to the market every
day. You need a basic understanding of how these products are
supposed to function and what features you should look for.
Fitting equipment is important for a number of reasons.
First, it is essential to place your body in correct balance to do
your work. Just improving ergonomics can begin to reverse the
discomfort and pain of RSI. A good workstation setup fosters
good posture, which starts you on the road to recovery.
Although your body is exible and adaptable, there is no reason
why it should be contorted to t a chair or a computer setup.
Your workstation should be tted so your body is not subjected
to strain and injury.
A well-thought-out ergonomic item should be adaptable to its
user. A keyboard as well as a chair must be easily adjustable. Be
critical when purchasing ergonomic equipment, as it may be
ergonomic in name only. Thousands of products are on the market making claims ranging from curing carpal tunnel syndrome
to solving all of your RSI problems, potential or actual. Make
your purchase based solely on your need for a more healthful
work space, and do it as an informed consumer. Many products
such as wrist rests, splints, and other advertised self-treatment
devices may be useless and in some cases even harmful. Remember that the best ergonomically designed workstation is useless to
you if have bad technique or are in poor physical condition.
Ergonomics: Making Your Equipment Fit
133
Chairs
When evaluating a workstation, I look at seating rst and build
the rest of the workstation around an ergonomically sound and
comfortable chair. A good chair can do much to help your posture. The chair should be soft upholstered but not very soft and
should have casters so you can move freely. Recently, chairs
with exible netting have become popular. One consideration
is size. A few of the high-end manufacturers make their chairs
in different sizes, although most chairs are of the one-size-tsall variety.
When selecting the chair, make sure that the seat pan supports you comfortably without your buttocks draping over the
edges. The seat pan should not be so long that it digs into the
back of your thighs, and its front should have a downwardrolled edge. The seat pan should ideally be adjustable so it can
tilt to allow the knees to be lower than the hips. Many chairs do
not have seat pan tilt, as it requires that the seat pan be separated
from the chairs back. If seat pan tilt is not available, a wedgeshaped pillow can be placed on the seat. It is this tilt that carries
some of the body weight to the feet and stabilizes the lower
spine. Having a seat pan that can slide backward and forward is
also desirable.
High-Backed Chairs
Avoid high-backed executive chairs if your work involves
heavy keyboard use. These chairs, while imposing, tend to lock
you in place and prevent free movement of the shoulder blades,
which is essential for shoulder and arm mobility. Chair backs
should be low enough to allow free shoulder movement.
Armrests
Avoid armrests entirely unless they can be moved out of the way
while working. Leaning on them while keying prevents you
134
from using the shoulder and upper back muscles, making your
forearms and hands do all the work. If you need armrests, they
should be the stubby kind, so you cant lean on them when you
type and they wont bump into the desk.
Easy Adjustability
My patients have complained about chairs with multiple levers
that are difcult to operate with their injuries. Look for a chair
that has a simple mechanism. Adjust the chair properly for computer work, and sit in it for a few minutes before you buy it.
Kneeling Chairs
Some people prefer backless kneeler chairs, made popular in
Scandinavian countries. They can place pressure on the knee
joints and should be used with caution. If you use a kneeling
chair, alternate it with a traditional chair while you work to distribute the muscle load of your body.
Standing
For those who are comfortable keying while standing or who
have to stand, as at an airlines reservation counter, the height of
your keyboard is important. Whenever you work without a
neutral wrist position you are endangering your upper body. If
your wrists are bent upward, as if you are pushing open a door,
you must change the height or the angle of the keyboard to prevent injury. Keyboard users who stand tend to ex their elbows
tightly, causing tension of the ulnar nerve at the elbow. They are
also more at risk for low back problems.
Footrests
Avoid angled footrests unless they are xed in place. If you need
one, it is better to have a footrest that keeps your foot at, though
above the ground. The footrest should be big enough to move
your feet around without falling off the edges. No foot-dangling.
If your legs are too short to reach the oor, get the right footrest.
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Desks
When manual typewriters were the standard, ofce desks often
had two levels: the standard desk height, about twenty-eight or
twenty-nine inches high, and the return, about twenty-six
inches high, where the typewriter was placed. This would place
the desk at the right height for writing and put the typewriter in
a comfortable position for manual typing. The chair would
swivel into either position for work. This conguration has
largely disappeared from the ofce.
A standard desk height is appropriate for writing and sorting
papers but is usually too high for keyboard placement. By placing the keyboard at desk height and resting your forearms on
the desktop, you get no help from the strong muscles of the
shoulders or the upper back. If your keyboard is at desk height,
you are reaching too high, clearly a recipe for trouble. Those
desks that come with a special keyboard pullout drawer that is
in a xed, at position and cannot be tilted, also are troublesome. Since the height of most desks is xed, adjustable pullout
trays can overcome some of the height problems.
Your desktop probably has a phone setup. Be sure you have it
placed where your hand can easily reach it and that you have a
headset jack on it. If you use the phone a lot while you use the
computer, a headset should be on your head! Never cradle the
telephone on your shoulder, and absolutely never when you are
using the computer. Cradling the phone is so injurious that you
should invest in your own headset if you cant get your employer
to supply you with one.
Pullout Trays
If you are doing more than one or two hours of keyboard work
at a time, a pullout tray with an adjustable negative tilt capability
as illustrated on the next page, is a good solution. These can
usually be attached to the underside of a desk or table. The tray
should be height-adjustable and should have negative tilt capabilitythat is, you should be able to tilt it away from you, and
136
Figure 20. The ideal position, particularly for a touch typist, is the negative tilt keyboard
tray as shown. Note the neutral wrist position.
not just pull it out at. A half-inch block or shim under the near
end of your keyboard will give a negative tilt if your at pullout
tray is low enough to keep your wrists in a neutral position. The
tilt makes the keys harder to see, so negative tilt trays work better for touch typists than for those who hunt and peck. The tray
should be large enough to accommodate a standard or split keyboard, with some space available for an input device such as a
mouse, track ball, or touch pad. Make sure your knees clear the
hinge attachment, since a central hinge can obstruct knee movement.
Some trays have an extra xed or sliding mouse bridge that
can be placed over the number keys. This feature is desirable,
since it keeps your hands and arms comfortably close in to the
keyboard. If you are not a touch typist, the pullout tray may be
difcult for you, and you may be forced to keep it at.
Computer Keyboards
No other piece of computer equipment has had more design
research and gone through more style changes than the com-
137
puter keyboard. Research has focused on key placement, size,

adjustability, touch, key pressure, and technical design. Still, the
keyboard that suits everyone has not yet appeared.
What kind of keyboard should you buy? Choosing a keyboard can be confusing, as there are so many available at a wide
range of prices. When you buy a new computer, it comes with a
standard keyboard, and if it is not comfortable or is causing you
pain, you will want to get one that suits your needs better. As
mentioned in chapter 2, the elbow carrying angle, which varies
from person to person, will affect the way you place your hands
as you hit the keys. The greater your carrying angle, the greater
the likelihood that you will need a split keyboard. In any case, I
believe a split keyboard is generally a good choice for everyone.
Virtually all keyboards now on the market have the cheaperto-manufacture membrane cushioning for keys, rather than the
more desirable individual spring loading for each key, which is
best for good touch feedback. Basically, three types of keyboards are available: traditional, xed split, and adjustable split.
The traditional keyboard is supplied with most home computers
and is usually what you will nd at your workstation. Some are
available with a number pad on the right side, while others are
alphanumeric or have a separate number keyboard.
The xed split keyboard has a split at an angle of about
twenty-four degrees and a slight downward taper on each end,
which takes the hand slightly out of the palms-down position.
Figure 21. The xed split keyboard is ideal for most people.
138
The number pad, on the right side, is at. The palm apron along
the front edge of these keyboards is not ergonomically sound
dont rely on it to support your palms. Small legs that prop up
the far end of the keyboard should not be used, since they
encourage extending your wrist, as when pushing a door open, a
harmful posture. If you purchase this type of keyboard, make
sure you have the right size of pullout tray.
There are several varieties of adjustable keyboards. These
keyboards can be placed in the traditional position, angled, and
even tented so the hands are no longer in the palms-down position
but are held somewhere between palms up and palms down.
According to Dr. Alan Hedge, an ergonomics researcher at
Cornell University, keying with the palms in a vertical position,
as in playing an accordion, allows the forearm tendons, which
move the ngers, to work more easily. Since you cannot see the
keys in this position, it is difcult or impossible for a nontouch
typist to use one, so vertical mirrors are installed on each side.
Many of the people who feel uncomfortable in the palms-down
position at the keyboard have tight forearm pronator and
supinator muscles, which need to be stretched. By placing the
adjustable keyboard at a tented angle of approximately thirty
degrees they might feel more comfortable during their retraining. See chapter 6 for details on exercises.
Figure 22. The adjustable keyboard is suitable for daily use as well as training. Note the
split spacebar.
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Hot Keys
Many keyboards have hot keys, which can cut down on repetitive activities. They are especially useful for persons at risk for
RSI because they diminish the workload. You can have a hot
key for Internet availability; e-mail; multimedia; sleep; and custom hot keys that you can program. Some keyboards also have
labels for CTRL key shortcuts. More of these options are available for PC users than for Mac users.
Touch and Tactile Feedback

Dr. David Rempel at UCLA and Dr. Thomas Armstrong at the
University of Michigan have done extensive research on the
amount of work spent in activating keys. Basically, this research
has shown that most of us press the keys with far greater force
than we need to. Most keyboards no longer have spring-loaded
keys, which are more costly to manufacture. Now a plastic or
rubber membrane cushions the keys, so that the sense of contact
is lost, as is the click that told you that you made contact. The
effort required to be sure youve struck the key increases your
workload and potential for injury.
Wrist Rests
The use of wrist rests is controversial. I prefer to call them wrist
guides and ask my patients to use them only as guides, because
resting the forearms on a wrist support while keying can be
harmful for several reasons. First, they take the upper arms
out of the process of keying, so you are overloading the forearm
and hand muscles and increasing your chances of injury.
Moreover, the wrist support tends to encourage potentially
harmful positioning, particularly wrist extension (bending your
wrist up, as in pushing a door open). With the wrist xed on
the wrist rest, there is a tendency to use a windshield-wiperlike
wrist motion, which is extra work and harmful. Finally, the wrist
rest places pressure over the carpal tunnel area, which is not a
good idea.
140
Movable cradles that attach to the desk to support your forearms, or chair arms that allow keying while you rest your arms
on the chair are potentially just as harmful.
The Virtual Keyboard

Some day you may be able to sit at a desk with a small projection
device in front of you and type on a projected keyboard. According to an article in the Scientic American of January 2003, a pair of
inventors came up with a concept of remote control for electronic
devices. This virtual keyboard called the Canesta Keyboard
Perception Chipset consists of three parts. To quote the article:
The device consists of a pattern projector, an infrared light
source and a sensor. The pattern projector uses a small laser
only 9 millimeters on each side to produce what looks like an
ordinary keyboard on a desk. According to the rst users of this
system, they found the lack of tactile feedback a problem, so a
click was added. It may take some time for people to get used to
this way of typing, which experienced typists at rst found
somewhat slower than a standard keyboard, although practice
may produce additional speed. The device offers the potential
for easily placing a keyboard in a comfortable position in almost
any work environment.
Laptop Computers
Laptop computers are now very popular in businesses, schools,
and homes. Thousands of students are taking laptops to class,
using them to take notes and look up data. Laptops have a number of ergonomic disadvantages. They are small and have a constricted keyboard. They can be heavy when carried or actually
used on your lap. The laptop screen is generally not separable
from the keyboard, making ergonomic placement difcult. Input
devices are miniaturized and difcult to operate. And there is
considerable variability in the brightness and clarity of laptop
screens.
141
For picture clarity, your best bet is to try laptops in a store,

where they can be compared side by side before buying. Try to
rent or borrow one to test it before buying. Special desks for laptops are now on the market; bring your laptop with you to try
them out. Always attach a normal keyboard to your laptop
when possible and set the screen at the proper height and angle.
Laptops: A Warning
Laptop computers are a great convenience, and the new
wireless systems make them even handier. If you have
ever used one without a desk support, you may have
noticed that they get hot! A Swedish researcher described
the case of a fty-year-old man who placed his laptop
computer on his lap and used it for about an hour (Lancet
360, no. 9346 [2002]:1704). The heat from the computer
was noticeable but not severe, causing a burning sensation in his thighs; the burning sensation disappeared
when he repositioned the laptop. The following day he
noticed swelling and irritation of his penis, followed by
redness and blistering on his scrotum. The blisters, which
were manifestations of a second-degree burn, burst and
became infected but ultimately healed. The slow burn
occurred even though he was fully dressed in trousers
and underwear. Needless to say, he was greatly inconvenienced. The laptop computer user should simply remember to keep a pillow or some form of cushioning between
the laptop and the lap.
Computer Input Devices

The Mouse
The mouse is a signicant source of injury for computer users.
These point-and-click devices generally conform to the shape of
142
your hand, are usually right-hand-oriented, and cause you to

ex your index or middle ngers to activate the screen arrow.
The thumb and opposing fourth and fth ngers usually grip
the mouse. If the grip is too intense, you risk getting thumb and
nger tendinitis.
There are great numbers of mice on the market with features that claim to make life easier for the user. Lately optical
mice have been introduced, which work on any surface but
glass. They seem to require less effort to move the arrow around
on the screen. Some mice have multiple functions similar to
those of hot keys.
Placement of the mouse is critical. When placed too high
and too far to the side, the
mouse can cause shoulder
and bicep tendinitis as well
as muscle fatigue. Ideally, the
mouse should be at the same
level as the keyboard and as
central to the body as practically possible. Hold the
Figure 23. The oating mouse tray allows the
mouse as loosely as possible,
mouse to move to a central and more comfortable
position.
with little or no gripping.
The Track Ball

This device is frequently used as a replacement for the standard
mouse. The track ball comes in different sizes but is generally
about the size of a golf ball set into a xed holder. Smaller rollers
can be found on some laptop computers.
There are certain advantages to the track ball. Since you
dont need a mouse pad, or a large surface to move around on,
you can place the track ball anywhere you want. Moving the
ball makes you use your stronger upper arm muscles more. As
long as your hand is held slightly cupped and relaxed, the track
ball is a good substitute for the mouse.
Dont overextend your ngers at out over the track ball,
because this will work the wrong muscles.
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The Touch Pad

The touch pad is operated by running a nger over its surface to
move the screen arrow. Like the track ball, you can place it
where it is most comfortable. In addition to the standard touch
pad, most laptops are now
equipped with a small, centrally located touch pad.
Researchers at the University of Michigan have
expressed some misgivings
about the touch pad based
on their ndings. I suspect
that this is because there is
a tendency to use one
extended finger to do all Figure 24. Touchpad showing proper use
the work. If your hand is
relaxed, your ngers are slightly curved, and you alternate the
ngers used, then the touch pad can be useful.
Other Input Devices

Wands, pens, joysticks, and other devices are on the market.
There are wireless mice that t on the ngers and work simply by
moving the ngers against each other. Tiny joysticks, set among
the keys, are used on some laptop computers, although they may
be difcult to control. Here you have to be your own judge.
There is no reason why you shouldnt alternate among any of the
various input devices to minimize the likelihood of injury.
Pens and Pencils

The original input device is the pen or pencil, and almost
everyone I have seen with RSI has difculty with them. Holding
the pen too tightly is a common problem. To break the tight
grip, widen the barrel of the pen by purchasing sponge curlers
used to set hair. Remove the plastic holder, then insert the pen
144
through the hole in the middle of the

curler. This provides a soft cushion for
the ngers and widens the grip.
Although there are also many
expensive pens that you can buy with
expanded cushioned bands, they are
less effective than the curler, which is
so cheap you can have one for each of
your writing instruments.
Figure 25. A hair curler with a

pen inserted inside can be far
more comfortable for writing.
Other Computer-Related
Ergonomic Factors
Document Holders
Document holders are particularly helpful if used correctly.
They attach to either side of the computer screen and have a clip
to hold one or more papers. Always place the document holder
on the side of your dominant eye. See chapter 4 for more details.
Monitors
The standard monitor consists of a cathode ray tube (CRT),
usually ranging from seventeen to twenty-one inches in size.
Companies may sell their own brand along with their computer,
or they can be purchased separately. Size is generally based on
the diagonal measurementa 17-inch CRT really has a viewable
image size of sixteen inches. If you work with graphics or
spreadsheets youll want a nineteen-inch screen or even a
twenty- or twenty-one-inch screen.
Flat-panel liquid crystal displays (LCDs) are becoming more
common and take up less room than a standard CRT and weigh
considerably less. Flat-panel displays give a very clear image but
have a more limited color range. An important consideration and
inherent disadvantage is that they are best viewed straight on
because contrast is lost as you move off center. Before buying a
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monitor, try it out in the store. Check to see if text is as clear on

the edges as at the center. Do the picture colors look clear and
natural? Compare the monitors side by side if you can.
LCD Projectors
LCD projectors attached to computers are usually used at conferences or meetings with presentation software to enlarge the
viewing area to a wall or screen. They also can give the visually
impaired a chance to work with computers, and in some cases,
may enhance a legally blind persons function at the computer.
New LCD or plasma TV screens also can be used to obtain a
large, comfortable picture.
Voice-Activated Software
Whether you have RSI or not, if you want to use voice recognition equipment, certain rules apply. A few hours of training with
a speech therapist may be helpful to teach you how to enunciate
properly, avoid slurring words, move smoothly through your dictation, and avoid straining your voice. Using the right microphone and placing it properly controls your speaking quality and
volume. Dont forget that voice-activated systems need lots of
RAM. Look for Internet Web sites such as http://www.
voicerecognition.net for guidance about what to buythe software is constantly being improved. The experience of one voiceactivated-software user (W. Wayne Gibbs, Scientific American, June
2002) is worth noting. He calculated that his voice recognition
system reduced his mousing by roughly a third in e-mail, by more
than half in le management, and by two-thirds in Web surng.
Changing Workstations
Many people change workstations daily or share them. Carry a
tape measure and use it to adjust your workstation so you have
consistent work conditions. This applies to the entire workstation, not just your chair measurements. Car manufacturers now
provide automatically adjustable smart seats to suit several
146
drivers using one car. Someday we may have smart chairs and
desks for computer users.
Ergonomics and Stress

Recently I came across some fascinating work by Dr. Erik Peper,
a professor of holistic health at San Francisco State University.
He points out that even if you have the best ergonomic setup
possible, just sitting down at your desk can produce physical
reactions that can increase stress. In his studies Dr. Peper found
that 95 percent of persons raised their shoulders as they sat
down at the computer. This observation impressed me because
it ties in with the postural problems we see so often in people
with RSI. Your ergonomic setup is supposed to get you into a
comfortable position, yet sitting down and shrugging your
shoulders is the very posture that will place more tension on an
important nerve area, the brachial plexus. Dr. Peper also noted
that 30 percent of people began shallow breathing as they sat at
the computer. He theorizes that computers, for whatever reason,
trigger a ght-or-ight response accompanied by an adrenaline
rush. Inhaling slowly can trigger the bodys relaxation response
and help to quiet this reaction. There are many stress reduction
techniques that can be very helpful, but the main thing is not to
drop your guard by thinking that good equipment alone will
protect you from injury.
Can these observations be applied to other activities? Does
the musician or the court stenographer raise shoulders or
breathe supercially beginning his or her activity? Is this a stress
reaction that is contributing to the genesis of injury? It seems to
me that more work needs to be done in this area and that Dr.
Pepers observations are a good starting point.
An Ergonomic Equipment Checklist

Here is a checklist of factors you should keep in mind as you set
up or improve your workstation:
Seating
___ Proper size seat pan for
your body
___ Seat pan has downwardrolled front edge
___ Adjustable seat pan tilt
___ Wedge pillow if no pan tilt
available
___ Seat pan moves both forward and backward
___ Seat back height adjustable
to allow shoulder movement
___ Ease of adjustment
___ Adjustable armrests or no
armrests
___ Short armrests that dont
bump into desk
___ Adjustable seat height
___ Adjustable backrest tilt
___ Soft seat
___ Movable on casters and
swivels
Footrest
___ Flat
___ Angled
Desk
___ Desk height
___ Arrangement of desk
equipment
Phone
___ Location
___ Phone jack
___ Phone headset
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Pullout Tray
___ Adjustable with negative tilt
___ Knee room
___ Large enough to accommodate keyboard
Keyboard
___ Standard
___ Fixed split
___ Adjustable split
Input Devices
___ Placement
___ Mouse: standard or
optical
___ Track ball
___ Touch pad
___ Joystick
___ Other
Monitor
___ CRT or LCD
___ Height
___ Size
___ Distance
___ Location
___ Tilt
___ Antiglare screen or shield
___ Flicker
Document Holder
___ Located closer to dominant
eye
Writing Tools
___ Ergonomic pen or
expander
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Where Are We Heading

in Ergonomics?
In 1999, the Department of Labor through its Occupational
Safety and Health Administration (OSHA) proposed a series of
workplace standards. The objective of these standards (29CFR
Part 1910) was to address the signicant risk of work-related
musculoskeletal disorders confronting workers in various jobs.
General industry employers covered by the standard would be
required to establish an ergonomic program containing some or
all of the elements typical of a successful ergonomics program as
outlined here:
Management leadership and employee participation
Job hazard analysis and control
Hazard information and reporting
Training
Work injury management
Program evaluation
Under the second Bush administration, the standards rapidly fell victim to House and Senate rejection, despite the many
years in preparation, partly because they were thought costly
and onerous to businesses, and partly because the standards
were cumbersome and confusing. Nevertheless, some state laws
preserve these or similar standards.
The proposed federal standards would have affected approximately 1.9 million employers and 27.3 million employees.
OSHA estimated that the standards would prevent about 3 million work-related injuries over the following ten years.
9
Biomechanics:
Using Your Body
Our body is a machine for living. It is organized for that,

it is its nature.
Leo Tolstoy (18281910), War and Peace
ur focus, in biomechanics, is how we interact with our tools

and how we can do so without incurring injury. There is an
important relationship between ergonomics, the external factor
or equipment, and biomechanics, the internal factor or the body.
The essence of this relationship is that optimal biomechanical
activity is easiest to achieve if the groundwork has been laid by
using ergonomically sound equipment. If you are not physically
and mentally t and your workstation is not adequately set up,
you cant expect to be able to use the equipment without injuring yourself, no matter how much you know about proper technique. Biomechanical training or retraining is the critical nal
step in a program that will help you recover from RSI.
149
150
The Importance of Training

and Retraining
Musicians are taught technique, which is a form of biomechanical training, as well as the basic elements of music. Unfortunately, most music teachers have little or no background in the
biomechanical or ergonomic aspects of musicianship and rely on
what tradition has taught them. The same is true for training to
use the computer, where emphasis is on learning to use software
and not how to set up a workstation ergonomically and use your
body in a biomechanically sound fashion.
A Personal Issue
Each of us has uniquely different physical characteristics. Some
of us have long arms or ngers. Some are double-jointed. Some
are tall, others short. The variations are innite. No two persons
position themselves at a workstation in the same way. They
move their bodies in ways that are subtly, and sometimes not so
subtly, different.
Equipment used must t the user properly, so that you can
move in a biomechanically safe way. Biomechanics is a personal
issuea cookbook approach is not acceptable. A ve-foot, twoinch woman and a six-foot man cannot share equipment that is
not adjusted for each of them.
A Dynamic Process
You can observe your movements, but you are likely to miss
many of the subtleties of potential injurious moves and postures
with the naked eye. Using videotape to document movement is
a very useful way of studying work habits.
I routinely videotape my patients at work or in a simulated
work setup. Time-lapse or real-time videotaping shows us what
Biomechanics: Using Your Body
151
we are doing with our bodies. Both the trainer and the subject
can study and correct awkward movements and positioning.
With video evaluation, what had formerly been a matter of
experience and a trained eye has become a partnership with the
patient. People are usually surprised when they see how poorly
they perform their work tasks. Try having someone videotape
you at your workstation and see what I mean.
Occupational physicians at the University of Connecticut
Occupational Health Service, where I am a consultant, are also
developing new techniques, such as infrared videotaping, as
diagnostic tools. This technique could reveal abnormal movements that need attention and set standards of movement.
Workstation Biomechanics
Posture
When your mother told you to sit up straight, she was right!
Throughout this book we have emphasized the importance of
good posture. Good posture is best achieved by correcting muscle imbalances. This includes stretching and strengthening muscles that have either sagged or tightened, and thereby developing
muscular balance among the neck, upper back, and chest. Even
breathing can be affected because of tightened muscles that
restrict rib cage movement.
Good posture is also helped by sitting in an easily adjustable
chair, positioning the keyboard and the monitor comfortably,
and having appropriate, specially corrected computer eyeglasses
when necessary. Be sure that you have your telephone placed
where your hand can easily reach it, and if you use the phone a
lot while you use the computer, a headset should be on your
head. Never cradle the telephone on your shoulder. See chapters
4 and 7 for more on this.
The postural deciencies most often seen among computer
users include rounded shoulders and a head thrust forward combined with shoulders that lack free range of motion. Postural
152
deterioration evolves over time in those who dont make efforts

to prevent it from occurring. Exercises to maintain or improve
posture are detailed in chapter 7.
Wearing a heavy backpack can damage your posture. For
years, hikers and outdoor people have used backpacks to carry
heavy loads of equipment, and now people are replacing handbags, briefcases, and schoolbags with backpacks. When used
indiscriminately, backpacks can lead to postural misalignment. A
particularly vulnerable group is young students, as we will see
later in this chapter.
Correcting your postural deciencies is one of the most
important things you can do, but it is hard to do without the
guidance of an occupational or physical therapist.
Positioning Yourself at the Computer

Dorsiexion or Wrist Extension
Look carefully at figure 26 and notice this common but
extremely harmful position. Compare it with gure 27.
Usually dorsiexion happens when the keyboard is placed
on a desk with the arms resting on the desk surface, which normally is too high for proper keying. In an attempt to do some-
Figure 26. The dorsiexed (extended) wrist is a biomechanically harmful position.
Figure 27. The neutral wrist position is biomechanically efcient.
153
thing ergonomic, many manufacturers have placed small,

retractable legs at the far end of the keyboardthe wrong end!
Using these makes matters worse by increasing the angle of the
extended wrist as you key. I havent been able to gure out why
these legs are placed there except perhaps as an attempt to imitate the step up of the mechanical typewriter.
The old typewriters, however, made it impossible to hit the
keys with your wrists and forearms on the desk, which forced
you to keep a neutral and correct position while typing. There
are clear reasons why dorsiexion is harmful. First, with the
wrist extended, one set of forearm muscles (the flexors) is
stretched, while another (the extensors) is shortened. The shortened muscles have to pull against the stronger set of exor muscles to keep the wrist in an extended position (static loading),
causing fatigue from overuse. Static loading occurs when the
muscle appears to be still, although it actually is working with
the added disadvantage of decreased blood supply.
The extended wrist position also
involves the exor muscle group of
the forearm in a detrimental way. The
exors are working to press the computer keys in a stretched state. This is
an example of eccentric muscle contraction. It is like pulling on an
already stretched rubber band, which
is the most harmful way a muscle can Figure 28. Dorsiexion is a harmful posture for computer users.
be used.
It is very important to keep the
wrist in a straight line (neutral position) so that tendons and
other soft-tissue structures glide in a more or less straight direction. This is sometimes more easily achieved if an under-thedesktop pullout tray for your keyboard is used and put into a
downward slope away from your body.
This position has an added advantage since it takes the elbow
beyond the ninety-degree right angle that we so often see in
ergonomic pictures. This right-angle position is incorrect because
it places more pull on the ulnar nerve at the elbow.
154
If you are not a touch typist

and feel you must keep your arms
on the desk surface, make sure
your chair is adjusted high enough
so you can maintain a neutral
wrist position and the shoulders
feel comfortable. In any case,
make sure you keep your feet
rmly on the oor or on a raised
platform if your feet dont reach
the oor. As you key and use the
mouse or other input device,
move your entire arm from the
shoulder, instead of just activating
the wrist.
Figure 29. Seated at the computer.

Wrists in a straight line, elbows slightly
open past ninety degrees, good lower
back support, feet on the oor, seat pan
tilted downward, keyboard tray tilted
downward, mouse close by
Ulnar and radial deviation

(windshield wiper wrists)
The next most common harmful position is ulnar and radial deviation.
This position subjects the forearm tendons to twist and kink
as they move the ngers. The consequences are strained and
inamed tendons, including lateral epicondylitis, DeQuervains
tenosynovitis, and overworked muscles.
Try to avoid the outer positions you see in gure 30, where
the hands move like a pair of windshield wipers. From a biomechanical standpoint, these movements
happen for a number of reasons. The
most common is limited shoulder use,
where placing the forearms on the desk
surface restricts the large muscles of the
shoulder from moving the arm. This is
common in people who key, use a mouse,
or play on a musical keyboard. The tendon kinking that results from ulnar and
radial deviation probably also contributes
Figure 30 (left to right). Radial
to carpal tunnel syndrome, by increasing
Deviation, Neutral, Ulnar Deviation
155
friction and causing swelling and inammation within the closed

space of the carpal tunnel. Some of the new keyboards now
available are angled to reduce the tendency to place the wrists in
ulnar deviation. Other keyboards may have a central adjustment, which enables the angle of the keyboard to vary.
The Carrying Angle at the Elbow
Another factor that contributes to increasing the likelihood of
ulnar and radial deviation relates to the carrying angle at the
elbow. We are all born with different carrying angles of a xed
angle for each person between the humerus and the ulnar bones.
Among my patients, this angle is usually 5 to 10 degrees for males.
Women normally have a greater angle, usually 10 to 15 degrees.
Compare gure 31 where the subject has a low angle, with
gure 32, where the subject has an increased angle. In gure 33
Figure 31. This person has low carrying

angle at the elbow.
Figure 32. This person has an increased

carrying angle at the elbow. Compare with
gure 31.
Figure 33. People with an increased carrying angle tend to go into ulnar deviation at
the standard keyboard.
Figure 34. Correction of the patient seen in

Figure 33 uses a split keyboard, resulting in
a neutral wrist position.
156
note the subject with hands in pronation placed on the standard

keyboard, and also note the resulting ulnar deviation, which is
corrected by splitting the keyboard, in gure 34. I recommend a
split keyboard for persons with a carrying angle greater than 10
degrees.
If you are overweight, your own body presents an obstacle
to placing your arms against your sides. Flexed arms are
pronated farther apart by the obese typist, who is forced to go
into ulnar deviation.
Finger hyperextension
Another common but harmful
keyboard technique is finger
hyperextension, which means
that instead of maintaining
curved ngers (so that you cant
see your ngernails), the ngers
are extended flat on the keyboard. People with short ngers
often get into trouble, straining
to reach a distant key. This
straining is often the cause of
pain in the forearm and elbow,
Figure 35. Congenitally short fourth

and fth ngers may be obstacles to
comfortable keying or playing certain
musical instruments.
extensor indicis m.
1. dorsal interosseous m.
dorsal aponeurosis
1. lumbrical m.
exor digitorum
supercialis m.
Figure 36. Muscles controlling nger movements. Intrinsics: lumbricals and interossei;
extrinsics: extensor indicis and exor digitorum supercialis. The rounded area at the knuckle
is where the dorsal hood is located.
157
which mysties the examining physician or therapist because the

connection between the short ngers and the biomechanics at
the keyboard is not recognized.
Women with long nails are more or less forced into hyperextension. Get rid of long nails, because they force you to hit the
keys with ngers extended. The maximum nail length for a typist should be 116 inch.
If we study the function of the hand, we see why hyperextension (holding the ngers completely at out) is harmful. This
concept is often poorly understood because it involves knowing
that the intrinsic muscles of the hand can have dual functions.
The muscles involved are called lumbricals and interossei (see
gure 36). The main function of the lumbricals is to ex the
ngers downward from the knuckle joints to the tips of the ngers. The main function of the interossei is to spread the ngers
apart and pull them together. In the case of the lumbricals, they
help the forearm exor muscles to ex the ngers. In hyperextension, however, both the lumbricals and the interossei act as
nger extensors, which means that they are lost as exors.
We have not only lost the intrinsic hand muscles as exors, to
help us hit the keyboard, but as extensors, they now work
against the forearm exor muscles as the extended ngers try to
hit the keys.
Try to ex your ngers while they are in extension and see
how much harder it is! Curve your ngers slightly and you will
have maximum nger mobility. It is important especially for
pianists to understand this concept.
Finger hyperexion
If the ngers are overexed (hyperexion), as in a st position,
they cannot spread apart but can be pulled together. Try this by
attempting to spread your fingers while making a fist. The
ngers can only be fully spread while they are extended (hyperextension). Hyperextension and hyperexion are extremes that
are inefcient for hand use. Between these two extreme hand
positions is a middle ground where the hand operates efciently
and safely.
158
Alienated or hyperextended thumb

In observing many people typing, especially those who touchtype, I have found a signicant percentage who are using only
one thumb to press the space bar. The unused thumb is constantly held up and outward, alienating it from the rest of the
typing ngers. Try holding one thumb in this position and you
will see that the ngers tend to hyperextend, making it more
difcult to ex them and placing greater strain on both hand and
forearm muscles. This causes loss of dexterity and efciency and
can lead to tendinitis at the base of the thumb. The group action
of the thumb and ngers is complex. To retrain yourself it may
be necessary, at least temporarily, to eliminate both thumbs
from keyboarding, which will slow your typing speed until you
heal. Normally, the faster you type the more likely you are to get
injured.
Figure 37. An alienated

thumb, held away from the
spacebar. This is an inefcient
use of hand muscles.
Thumb hyperexion
Moving the thumb downward and tucking it under the palm is
commonly seen among musicians doing arpeggios and occasionally among typists. This repetitive thumb hyperexion can
cause DeQuervains tenosynovitis.
Unusual Biomechanical Actions

Kneading
Some keyboard users continually ex and extend their ngers
while at the keyboard in a dough-kneading action. This is an
inefcient movement that increases their workload substantially
and predisposes them to greater likelihood of injury.
159
Clacking
Clackers hit the keys much harder than necessary. Only slight
pressure is necessary to activate computer keys, yet many people
pound so hard that one can hear them from far off. This technique aberration can be a sign of stress or simply a bad habit. It
literally adds tons of pressure that you need not exert. Certain of
my patients who have complained of ngertip pain or numbness
when examined, turn out to be clackers. They may also be at
risk for developing vibration syndrome. So lighten up! Practice
lighter touch by gradually teaching yourself to control the force
of the stroke.
Incorrect mouse use
Another source of thumb tendinitis is the mouse. Although
mouse placement is critical to prevent arm and shoulder problems, it is the gripping of the mouse that leads to a disabling
thumb tendinitis. Having the mouse higher than the keyboard
(exion) or too far to the side (ulnar or radial deviation) or using
it with the wrist bent up (extension) are all awkward positions
that need to be corrected with biomechanical retraining. Some
typists stretch their ngers at out while using the mouse, the
touch pad, or a track ball, which is very inefcient because it pits
the exor muscles against the extensors.
RSI and Kids

Backpacks carried by the current generation of students have
become mobile lockers. The average student carries a backpack
that can weigh twenty pounds or more, and orthopedists are
reporting more and more children with back pain. A recent
study by the American Academy of Orthopedic Surgeons
reported that 58 percent of orthopedists saw children complaining of back and shoulder pain caused by these heavy backpacks.
These are the same students who are likely to spend many
hours at computer keyboards and as they grow older become
160
more and more at risk for the type of postural-related injury we

discuss in this book. The American Academy of Orthopedic
Surgeons recommends that a backpack should not exceed 20
percent of a childs body weight. If you are feeling pain, try
avoiding backpack use for two weeks; if the pain subsides, then
the cause is probably the backpack. First, try to eliminate all
unnecessary books. For any backpack user, an upper body exercise program should be part of the daily routine. Kids might not
think theyre cool, but backpacks on wheels are now available
and should be considered.
By the time growth ceasesusually between fourteen and
seventeenchildren become more susceptible to injury. This is
especially true for young musicians and athletes. There are
several reasons for this. Soft tissues that were once extremely pliable begin to assume an adult conguration, and postural characteristics begin to solidify. Growth hormone levels diminish,
resulting in a decreased capacity for muscle regeneration. A
body once capable of overcoming biomechanical and ergonomic
deciencies becomes more susceptible to injury. Without early
education and prevention, the risk of injury increases.
Schools, Posture, and Computers

Researchers at Cornell University have confirmed my own
observation that many of the elementary school computer labs
are not set up with healthy typing posture in mind. A 1999 study
of schools by Shawn Oates appeared in the journal Computers in
the Schools and found striking mists between children and
computer workstations. Typically, keyboards and monitors were
placed too high. Hunched shoulders, awkward wrist positions,
and hyperextended necks were some of the ndings.
My own observations suggest that this situation also exists in
the classrooms and libraries of colleges and universities. Graduate students working long hours on their theses seem particularly susceptible. Another less obvious area is the home, where
young students use computers set up for their parents.
Yips in Golfers
Sports can not only contribute to symptoms of RSI, but
also can be affected by it. This is especially true where
precision of movement is required. An article in the Wall
Street Journal of February 19, 2003, described a curious
condition that golfers call yips. A golfer with yips would
notice spasmodic jerking as he or she crouched over a
putt, often causing the golfer to miss. The condition has
been studied at the Mayo Clinic, where a denitive conclusion as to its origin has not been reached. No one is
sure whether the condition is physical, mental, or both.
Some suggest it may be a form of focal dystonia (see
chapter 13).
I have seen several golfers with similar symptoms.
These were recreational golfers who worked in fields
requiring computer use. In these patients, I found postural
problems and other troubles, including neurogenic thoracic outlet. I instructed them to bring their clubs to the
next visit so we could videotape their actions. The results
were revealing. While putting, their shoulders were
rounded and their heads were thrust forward, a position
that can compress the nerves of the brachial plexus
between two scalene muscles of the neck. The golf swing
put traction and compression on these same nerves.
In my limited experience, yips was not much different from other RSI cases where posture plays a role in
compromising the function of the muscles in the arms,
forearms, and hands because of brachial plexus injury.
The role of stress and resulting psychological problems
have been suggested as factors contributing to yips.
The few golfers I have seen did improve with a regimen of
physical therapy, home exercises, and psychological
counseling. Anyone presenting with yips symptoms
should be thoroughly examined to obtain a diagnosis, just
like anyone who presents with symptoms of RSI and its
complications.
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10
At Home
with RSI
Mid pleasures and palaces though we may roam

Be it ever so humble, theres no place like home.
J. H. Payne (17911852)
The term activities of daily living applies to the ordinary

things you do every dayusing the computer, driving, talking on
the phone, reading a book or newspaper, brushing your teeth,
cooking, gardening, opening doors, turning faucet knobs, and
hundreds of others. Normally, we perform these functions easily,
without noticing we are doing them. For someone suffering
from RSI, these tasks may become a huge burden because of
pain and weakness. These physical shortcomings can be heightened by a sense of frustration, helplessness, anxiety, panic, and
depression. Some of these day-to-day tasks can be made easier
by doing things differently and using tools that can help.
When you are recovering from RSI, improvement in the
ability to perform tasks is an important sign that you are getting
better. During your initial physical evaluation, discussing your
limitations in activities of daily living can aid in the diagnosis of
your illness. These functional limits give your physician and
163
164
therapists information about what activities may be contributing

to your injury outside of work.
The following suggestions come from a variety of sources,
including patients, therapists, and health and safety committees.
Lisa Sattler M.S., P.T., a physical therapist who specializes in
treating patients with RSI (she has a Web site at http://www.
lisasattler.com), and Vera Wills, a musicians ergonomist, have
also been extremely helpful in providing me with information
derived from their own experience.
Most people with RSI can handle the activities of daily living
to a limited degree if they pace themselves. Athletes are trained
to pace themselves. The same should be true for those who perform ordinary everyday activities. Pacing your work over several
hours may get you through the tasks of the day without incurring increasing pain that forces you to stop work entirely.
Share Your Chores

Many of my RSI patients can be helped to maintain their households by sharing chores when they nd they can no longer do
them alone. Divide chores by abilities, so that you get to do the
ones that dont cause you pain or difculty. Another answer
may be to delegate chores when possible. It is infuriating for an
injured person who is in pain to have his or her children or
spouse refuse to help out. A delicate balance needs to be struck
between having to share your chores with members of your
family and having them become caretakers. A serious discussion
about the role of the household members needs to take place.
This kind of family interaction can be an emotional struggle,
and professional help may be needed.
If You Live Alone

Be inventive in doing your household chores. Perhaps setting
slightly lower standards of neatness by letting go for a while and
At Home with RSI
165
pacing yourself would be a desirable means of coping. For

women, modify your hairstyle to a wash-and-wear style. Give
up panty hosetheyre too hard to pull on and off. Wear slip-on
shoes with wedge-shaped, nearly at heels and Velcro closures.
Men should consider growing a well-kept beard if they cant
shave easily. When you get new clothing, opt for items that you
can put on easily, such as with elastic waists and loosely t.
If You Can, Hire a Housekeeper,

Cook, or Helper
When you are ill or disabled, a helper ceases to be a luxury. A
great burden of work can be lifted if there is someone to clean,
cook, or do choresand there are resources for people who cant
afford to hire someone on their own. Meals that can be prescribed by your physician from social agencies or your church
group and part-time helpers from organizations such as the Visiting Nurses Association may be means of coping. RSI self-help
groups may be able to identify other resources. Refer to the
Internet resources section for more information.
The Telephone
If you are using the phone a lot, a headset should always be
attached to the phone. Patients report that this is especially important in the kitchen, where the hands are occupied with cooking
chores. Headsets also come in a cordless form. Various types of
headphones are available from the Hello Direct Catalog (1-800444-3556) or from Staples and Radio Shack, among others.
Cellular phones are becoming commonplace replacements
for the home phone. Gripping these tiny phones while holding
them to your ear and tilting your head is similar to holding a
computer mouse to your earuncomfortable for anyone, not
just RSI sufferers. Earpieces can ease the muscular burden.
166
Voice dialing is available from most phone companies. Technological advances in phoning are occurring rapidly, and phones
now have caller ID and number storage that dial with the press
of a single button. Keep yourself informed about other worksaving services available from your phone company
Sleeping
Sleep promotes healing. Normally, we all spend a third of our
lives in bed. Unfortunately, the time you spend reading in bed
can only contribute to your problems if you are injuring yourself
while you do it. Most people with RSI have postural problems
involving their necks. Curving your spine and neck to see the
TV screen or reading a book when your hands hurt and you
cant support the book doubles your trouble. Learn to sit while
you read or watch television. Save your bed for restorative
sleep, sexual activity, and relaxation.
Positioning yourself for restorative sleep involves protecting
your arms, keeping them relaxed, and not bending at the elbow
or wrist. Some people can do this by sleeping on their backs with
pillow supports under each arm. An easier method is to use soft
cushioning as a splint (only while you sleep) to limit the bending
of elbows and wrists. This can be achieved by wrapping your
arms in cotton rolls under a loose elastic bandage. Your health
care provider can help you nd the right solution.
The words restorative sleep are to be taken seriously; get
as close to eight hours a night as you can, but dont spend all
your time in bed. When depressed, people often spend a lot of
time in bed, but their sleep is tful and not restorative. If you feel
your sleep disturbance is due to depression, you should consult
a psychiatrist. If you are seeing more than one physician, be sure
each knows what medications you are taking.
Sleeping medications have both positive and negative effects
on people with RSI. While they can help you get to sleep,
almost all aids for sleeping disturb REM sleep, which is necessary for restorative sleep. If you use sleep medications, but nd
At Home with RSI
167
you are nevertheless restless and waking up during the night, try
to cut down on the pills with your physicians supervision, as
withdrawal symptoms are possible. Caffeine and alcoholic beverages also can disturb healthful sleep and should be limited.
Sexual Activity
Sex may pose a problem if you have RSI, and here you have to
turn to both practical and inventive solutions. We all need love
and affection, and sexual activity is naturally a part of our emotional lives. Fortunately, we live in a time where we can nd
solutions in the library or advice from professional sources. As
in other aspects of RSI, there are solutions to the physical limitations you are experiencing. Keep in mind that affectionate conversation with your partner will do more to help your sex life
than acrimonious confrontation.
Relaxation
The very fact that you have RSI may indicate that you are normally a busy, active, or tense person. Learning to let go and relax
is one of your tasks. High stress levels can affect your recovery
and your therapy. Some activities that have helped our patients
relax include music, theater, dance, self-awareness programs,
body awareness programs, meditation, modied yoga, retreats or
vacations, and lifestyle changes that can mean anything from
modifying the way you work, to changing your job, to moving to
a new location, to changing your exercise and diet regimen. Seek
the help of a mental health professional to guide you to activities
that will relax you. See chapter 3 for more information.
Reading
In my experience, the last activity to improve during recovery is
the ability to read comfortably holding a book or newspaper. A
168
reading stand or a special pillow to prop up the book is available

from sources such as the Levenger Company (1-800-544-0880).
You simply cant turn pages? Books on tape are useful for RSI
sufferers. Slip-on rubber ngers also are useful for turning pages.
Special book weights can be used to hold books open for reading.
Hand and Finger Movement

Most of my patients who developed RSI doing computer work
also have difculty with handwriting. Here are a few pointers
that can help. Certain pens are easier to use than others. A standard ballpoint requires uncomfortably tight gripping and pressing. Fat pens are available for better gripping. A fountain pen
with a smooth-owing point can be easier to use than a typical
ballpoint pen. Vera Wills recommends the Pilot Precise V7 ne
rolling ball pen because it ows easily across the paper, and there
are other brands of rolling ball pens as well. A sponge hair
curler also can help ease the strain of gripping the pen (see gure
25). As with any other activity, writing requires that you pace
yourself. Use printed address labels so you dont have to keep
writing your return address on bills and documents. If you write
to someone regularly, make your own mailing labels. Voice-activated computer technology may be useful for home computer
work and help with bill paying as well as writing. See the details
in chapter 8. An electric stapler, electric scissors, and an electric
letter opener will help save your hands. Use self-adhesive stamps
and envelopes to minimize the chore of pressing.
In the Kitchen
A phone with a headset or a hands-free speakerphone is essential kitchen communication equipment. Paper plates and plastic
utensils can be bought in bulk and used to avoid washing dishes.
If you insist on washing dishes, get a dishwashing sponge with a
soap-lled handle. Soak the dishes before you clean them. An
At Home with RSI
169
automatic dishwasher can also be helpful, but of course it

requires loading and unloading.
Use the type of Chinese cutting knife that has two handles,
allowing you to rock it through the food you are cutting. Buy an
electric can opener and a light iron, and look into various types
of ergonomic kitchen utensils, including those that are designed
for arthritics. The Oxo Company makes tools with soft handles
that are available in household stores. Special jar openers also
are available. Remember to dip the jar caps in hot water before
opening. Scissors used in the kitchen should have spring-loaded
handles. When buying groceries, buy small sizes if you have to
carry them, or get an easy-to-push four-wheeled shopping cart.
If possible, have your groceries delivered. If you redesign your
kitchen, seek the help of a disability specialist or ergonomist
who might recommend changing counter heights, setting up
foot pedal faucets, or changing doorknobs to the easier-to-open
lever type.
In the Bathroom
Electric toothbrushes are available that can be held with a st grip
if your thumb hurts. Lightweight hair dryers also are available.
Taking a shower instead of a bath can avoid the strain of getting
into and pulling yourself out of your tub. Look into changing the
water taps to the lever kind they use in hospitals and installing
handle grips to help you get in and out of the shower or tub. Use
wall dispensers for shampoo and other liquids.
Driving
For most of us, the car is indispensable, but for a person with
RSI, driving can become difcult or impossible. Cars are not the
ergonomic triumphs that many manufacturers would have us
believe. We may sit slumped in the car seat, often forced to
look up or down depending on our body build and how much
170
headroom the car allows us. Since RSI is essentially an upperbody illness, the various activities of drivingmoving the neck in
various directions. gripping the wheel and moving it, shifting
gears, and getting in and out of the vehicleall can trigger symptoms or even cause a relapse during recovery. Be practical in
your choice of vehicle. Driving an SUV means you are adding
to your physical burden by pulling yourself up into the vehicle
and driving a small truck. Try items that have worked for others, such as foam cushioning on the steering wheel, wheelchair
gloves, or lumbar support pillows to keep you propped up at the
steering wheel. Electronically adjustable seats should be something to look for if you are getting a new car.
Become a passenger whenever you can. If you go on long
trips and are driving, stop by the roadside every forty-ve minutes to an hour to rest for ve to ten minutes. Know your limitationsdont wait for pain to tell you to stop. If you can only
drive for thirty minutes before the onset of symptoms, stop after
twenty minutes. Resume driving only after a sufficient rest
break, which you can determine by experience.
You will have to add your own tips to the ones in this chapter.
Be inventive about the things you absolutely must do, and give
up the things you can dispense with. Above all, take help where
you can get it, and remember to save your upper body for home
exercises and the important work of getting better.
11
Getting Back
to Work
It is the Age of Machinery, in every outward and inward

sense of that word.
Thomas Carlyle (17951881), Signs of the Times
The eld of occupational medicine had its beginning in the

eighteenth century, when Bernardino Ramazzini studied people
at work and used that knowledge to describe a type of physical
illness that had never been reported before his time. As result of
his work published in 1713, he is considered the father of occupational medicine. Were Ramazzini around today, he would
note that the computers at keyboard has created a work hazard far greater than what occurred with the invention of the
typewriter.
In 1808, Pellegrino Turri made, for a blind friend, what is
probably the rst mechanical typewriter. Commercial production began in 1870 with the invention of the writing ball by a
Danish poet and part-time inventor named Malling Hansen.
The modern mechanical typewriter dates to 1873, when Sholes
and Glidden introduced the rst typewriter with a QWERTY
keyboard, manufactured for the American market by the Remington Arms Company.
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172
Figure 38. The Malling Hansen writing ball
Figure 39. The Sholes and Glidden typewriter, the worlds rst commercially
successful typewriter
The QWERTY keyboard was designed to separate frequently used type bars so that they could not lock together
when struck. While the stepped keyboard of the mechanical
typewriter is gone, we still have the QWERTY layout, now on a
flattened electronic keyboard, which became popular in the
early 1980s with the introduction of the PC. Attempts to introduce other keyboard congurations such as the DVORAK layout (see gure 40) have not been generally accepted, although
those who have learned the DVORAK claim it is far more comfortable than the standard conguration. Whacking away at a
standard typewriters stepped mechanical keyboard did not cre-
Figure 40. The Dvorak keyboard, an idea that didnt quite catch on
Getting Back to Work
173
ate the injuries we see today, because the typist had to use more
of the upper body than we now use tapping the at keys with
only our forearms and hands. Excessive work at the mechanical
typewriter was more likely to produce sore shoulders.
Frederick Winslow Taylor was a highly educated engineer
who developed a number of industrial innovations, including
time-and-motion study. His book Principles of Scientific Management, published in the late nineteenth century, led to the highspeed assembly line, stripping work of many of its rewarding
aspects. His concepts were adopted worldwide, and established
him as the father of scientic management. Work became harder,
more boring, faster, and more stressful for industrial workers and
ofce workers, yet his work is one of the basic approaches to
industry today. He was the rst real efciency expert.
The concept of Taylorism, and the at computer keyboard,
which can respond faster than any typist can key, exposed ofce
workers to the illnesses of repetitive motion as never before.
This was further aggravated by the introduction of the mouse
and the CRT monitor, which added to the dimensions of injury.
The personal computer has now been an integral part of our
daily lives for at least the past twenty years, and to deal with the
workplace injuries resulting from its use, the Occupational Safety
and Health Administration (OSHA) issued standards and rules
to protect employees from RSI in many industries. Employers in
general considered these rules too costly, despite Californias
successful adoption of a similar set of rules. In January 2001, the
National Academy of Sciences, issued a report called Musculoskeletal Disorders and the Workplace, which stated that 1 million injuries were caused by repetitive motions on the job along
with other work-related ergonomic factors. The report stated that
a conservative estimate of the cost of these injuries was $50 billion a year. According to an article in the New York Times, some
corporate groups estimated that the new rules would cost $120
billion while OSHA put the cost at $4.5 billion.
When employers realize that they can save money by preventing RSI, we should then see more adoption of prevention
174
programs. There are enlightened employers known in the health

care community for their pioneering approach to prevention
L. L. Bean, Blue Cross/Blue Shield of California, the New York
Times, and the Los Angeles Times, among many others.
If an injury reporting system is set up to ag ergonomic trouble spots, the potential problems can be identied and corrected.
There are many highly successful employee injury prevention
programs that have produced a marked decrease in employee
injury, and studies have shown that industry predictions about
the costs of a preventive program are often far off target. Companies that employ full- or part-time physical therapists and that
provide tness facilities have fewer RSI problems among their
staff. Small businesses can enlist community facilities as a support system for prevention programs and can contract for
ergonomic consultation services.
The workers compensation system, which may differ
slightly from state to state, is an insurance program established,
in part, to pay for the medical care of injured workers. If you are
ling for workers compensation benets call your local ofce,
ask questions, and obtain informational literature from them.
Unions, some companies, and local RSI self-help groups distribute workers compensation information. Remember that the
trade-off when receiving workers compensation benets is that
when you sign on to the system, your right to sue your
employer is markedly diminished.
Recent studies suggest that many people are reluctant to
report RSI to the workers compensation system. One article
reports that only one in every eleven injuries is actually
reported. In my own experience, 60 percent of RSI patients continued to work despite the fact that they were injured.
Unfortunately, the workers compensation system has many
aws. Physicians are generally paid low fees, which is a disincentive to perform the thorough examination necessary for the
proper diagnosis of RSI. Workers comp physicians are often
surgical specialists who are faced with treating RSI, a nonsurgical illness. Often, workers comp physicians balk at attributing
175
the patients injury to workall too often the case when independent medical examiners (IMEs) are required to substantiate
a diagnosis. IMEs are employed by insurance companies to
protect the insurance companies from fraud and simply to save
money, which can create a conict of interest. For a variety of
reasons, the patient is often thwarted in his or her attempt to
prove the relationship of his or her injury to work. Bureaucratic
entanglement causes delays, and patients can wait months
before being certied for treatment.
If your workers compensation claim is not approved, its
time to think about an attorney. In a contested case, the
insurance company will have a representative at your hearing.
It is wise to have someone representing you. The attorney
you choose should be experienced in workers compensation
litigation.
Back to Work
Once you have RSI and are in treatment, you will have to start
thinking about returning to full- or part-time work, the most difcult nonhealth-related challenge you will face with RSI. To
achieve a return to normal function, there are certain goals that
you will need to meet.
You must participate actively in your rehabilitation. Passive
participation simply will not be enough to get you through your
treatment. No therapist can do your home therapy for you, and
you make no progress without your home or gym work. Maintaining the stretching and strengthening exercises is what
advances your professionally supervised therapy.
You will have to learn by trial and error to limit both work
and nonwork activities before you feel pain. One way to do this
is to time an activity and note when you begin to feel uncomfortable or feel pain. Limit this activity to a few minutes short of
the onset of pain the next time you do the activity, and become
aware of the feeling you get when pain is about to ensue. With
176
activities of daily living, you have to discipline yourself so you

dont schedule more than you can achieve. Above all, you must
attain and maintain good posture, because we know that bad
posture is a trigger for harmful injuries of RSI.
An important part of retraining is to note what your upper
body feels like when it is no longer tight, and when the larger
muscles of your upper back begin to work in conjunction with
the shoulder, arm, and hand muscles. This sense memory
should be recalled whenever you are exercising. You must limit
pressure on neck and shoulder muscles and nerves, which
means you should no longer carry heavy knapsacks, shoulder
bags, briefcases, or shopping bags.
You must become aware of awkward positioning and activities during retraining. Even seemingly minor things such as
keeping your nails short is important so you avoid inefcient use
of your hands. Take sufcient rest breaks from any potentially
harmful activities. Five to ten minutes every hour for ofce
workers is a good idea.
Retraining for work should be done in a structured and
orderly fashion so there is a gradual resumption of activities that
previously caused symptoms. Know your limits: getting an idea
of the severity of your injury is very important and can be useful in helping you determine whether you are ready to return to
work. Impulsive behavior and a rapid return to full activity
because you are feeling better can lead to a are-up and delay
recovery.
Adherence to your rehabilitation program and your awareness of the extent of your injury will keep you from a major
relapse. Rehabilitation will probably take longer than you like,
and you may have an occasional relapse, but keep at it!
People you work with may become problems. If they dont
understand what you are going through, they may resent having
to pick up some of the slack from you. If you are recovering
from RSI and have returned to work, you may feel pressure to
resume your usual pace. Dont do it. Instead, try to make your
fellow workers understand what you are going through.
The Case of Dr. M

Dr. M is a devoted and conscientious eye surgeon who
specializes in cataract operations. For several weeks each
year, he spent time in developing countries removing
cataracts from those otherwise unable to afford the operation. Cataract surgery involves intensive and delicate use
of the hands and ngers, and absolute control is required
to release the clouded lens and to suture the wound with
tiny stitches. Dr. M does this work almost continuously all
day long, crouching over the patient through most of the
work. Over time, this took its toll on his posture, leading to
the cascade of events common in RSI patients.
When he came to me, he was in constant pain and visibly upset because he could no longer work effectively. He
saw his career going down the tubes. He had been to
see his primary care physician, who referred him to an
orthopedic surgeon. Dr. M followed the suggestions of the
orthopedist, but his condition did not improve. In fact,
even though he wasnt working, his symptoms got worse.
Other physicians he consulted told him he had RSI and
suggested rest and nonsteroidal anti-inammatory medications. These had only marginal effects.
When I rst saw him, he was somewhat skeptical of
the ability of his fellow physicians to help, and he considered me his last resort. I spent a great deal of time on his
examination, explaining what I was doing all along the
way. The evaluation showed typical ndings. Over the
years, his posture had deteriorated, his head was thrust
forward, and the compression and traction of the nerves
in his neck had caused pain in his arm and hands. I
offered him specific diagnoses and recommended he
work with a physical therapist whose specialty was RSI. At
the end of the exam I sensed that he was still dubious.
Nevertheless, he began working with the therapist, who
did soft-tissue work and started Dr. M on a series of
focused home exercises and strengthening activities.
After about a month, Dr. M. reported improvement.
After six months, he was able to resume a full work
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178
schedule while continuing his exercise and strengthening

program. Dr. M also made some changes in the way he
set himself up at the operating table. He got into a more
comfortable and ergonomically less harmful position. He
paced himself and made other lifestyle changes. The letter
of thanks I received from him was touching, and I had the
satisfaction of knowing I had helped bring back a physician who was now able to continue his important work.
Are You Ready to Return?

Here are some criteria you can use to determine your level of
symptoms and capabilities in judging whether you can return to
work or other activities. These are helpful but are only to be
used as a rough guide.
Completely Limited
Here you are unable to perform any activities of daily living or
work activities without setting off symptoms that may last weeks
or even months. These symptoms are usually constant and
include aches, pain, numbness, tingling, and spasms. Obviously,
return to work is out of the question.
Very Limited
You can awake pain-free and perform four or ve arm-related
activities before the onset of pain and other symptoms. These
symptoms can last for several hours, decrease with rest, and
increase with further hand activity. The symptoms are usually
gone by the next day. Return to work cannot proceed easily
under these circumstances.
Moderately Limited
For brief periods, you can perform activities of daily living and
work-related activities without the onset of symptoms. You are
179
free of pain most of the time except after strenuous hand and
arm activity. A low level of sustained activity is tolerated, but if
limits are exceeded, pain may last for the next day or two. If this
is your situation, limited work with numerous rest breaks is possible provided discipline is maintained.
Mildly Limited
You are pain-free most of the time unless activities are pushed
beyond ordinary functional levels. Accordingly, short deadlines
and binge work must be avoided. Work is possible, but only after
establishing the need for these limitations with the employer and
fellow employees who may feel they are carrying your load.
The Difcult Activities
If you are in constant pain and having difculty deciding
which activities are likely to cause you the most trouble
during your rehabilitation, this list of particularly harmful
activities compiled by our patients can be useful:
Carrying a heavy backpack

Putting on makeup
Combing or blowdrying hair
Sexual activity
Cooking
Shaking hands
Holding a book or newspaper
Shopping, carrying groceries
Knitting
Using a scissors
Opening mail
Vacuuming
Pulling a shopping cart
Walking the dog
Pulling doorknobs
Washing dishes
Putting on clothing
Writing
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Computer Problems
Certain kinds of computer use are more challenging than others,
and more likely to cause pain.
Artists who do computer graphics and who probably are at
greater risk for injury because of intensive mouse use
Architects and draftsmen who use special input devices such
as the puck, which has numerous buttons
Typists who do data input work, particularly if they are subject to deadlines and binge work
Telephone operators who transcribe telephone calls for the
deaf
Typists who do television subtitles for the deaf, or who provide directory information
Temporary word processors who work under time pressure
and who must go from one temporary workstation to another
Anyone who must keep a fast and constant pace
The Functional Capacity Evaluation

Occasionally, during your illness or just about when you are
ready to return to work, you may be asked by your insurance
provider to submit to a functional capacity evaluation, a standardized test that purports to establish your ability to return to
work. In many instances this testing is done too soon or does
not evaluate some of the actual things you will be doing. Obviously, if this test is performed on a severely injured person, it is
a foregone conclusion that the result of the test will not be helpful except to establish a baseline. Often the testing itself can provoke a relapse. A functional capacity evaluation, usually done
by an occupational therapist, is designed to describe the individuals current lifestyle and observe his or her performance with
appropriate levels of work-related tasks. These include tests of
181
arm dexterity, upper-extremity coordination, and the effect of

speed on function. The examination also tests strength in gripping, pinching, lifting, and carrying, and makes observations of
mobility, static posture, weight-bearing ability, and balance.
From these observations, conclusions are drawn about your
ability to return to work and what the limitations of that work
might be. These tests are abstracts of standard capabilities and
may not reect what you actually do at work.
Returning to work is not a decision to be taken lightly.
Although most people are eager to get back, returning too early
can be disastrous. It is worth the effort to give careful consideration to your physical state before you decide to go back.
12
RSI and
Musicians
Music, the greatest good that mortals know, and all of

heaven we have below.
Joseph Addison (16721719), A Song for St. Cecilias Day
y interest in RSI began in a facility I established for the

treatment of injured musicians. Musicians need physical conditioning, but this fact is often ignored in the traditional music
schools and conservatories. Music pedagogy is very traditional
and still relies on the many years of experience passed down
through generations. We are losing many talented musicians to
injury early in their careers because they (and their teachers)
ignore the need for physical conditioning and lack the necessary
knowledge to use biomechanically correct technique to prevent
injury. Dancers, on the other hand, have learned that just dancing is not enough to keep them in shape and prevent injury.
This is why we see dancers doing weight training, stretching,
and strengthening exercises. Those lucky musical students
who are in an enlightened training environment are doing these
exercises, too.
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184
By applying concepts of physical conditioning, ergonomics,

and biomechanics, musicians can not only prevent injury but
also gain a competitive edge: the quality of the music delivered
will improve because of better positioning, greater strength, and
ner muscular control.
When a physical examination is performed on an injured
musician we are likely to nd the same kinds of problems that
we have described in this book for computer users and other
workers, with only slight differences. Emotionally speaking,
musicians are very caught up in their music; when an injury
occurs it can be psychologically devastating, threatening to undo
years of study and hard work. The ergonomic and biomechanical aspects of the treatment of musicians are very specic. Biomechanical retraining, something akin to technique training, is
better managed with the help of a knowledgeable fellow musician who can communicate more easily with the injured musician, especially when it comes to changes in fingering or
repertoire. With a combination of musical biomechanical
retraining and the physical and occupational therapy that is
always required in RSI injury, the results can be spectacular.
Which Musicians Get Injured?

If we look at the group of musicians who came to our facility in
the rst two years of its operation, we can see that piano and
string instrument injuries predominate. This suggests that these
very popular instruments pose the greatest ergonomic and biomechanical challenges. Of course, it is also possible that there
are simply more people playing these particular instruments
than others.
Here is a breakdown of 401 musicians in a study I performed who sustained injury as a result of playing their instrument over a two-year period:
RSI and Musicians
185
Instrument
No. of Musicians Injured

per Instrument
Keyboard
piano
harpsichord
organ
__________
Total
133
3
1
______________________________
137 (34 percent of musician injuries)
Woodwind/Brass
ute
oboe
clarinet
saxophone
bassoon
French horn
trumpet
trombone
__________
Total
13
6
9
2
4
9
4
3
______________________________
Percussion
drums
vibraphone
__________
Total
29
1
______________________________
Strings
violin
guitar
viola
double bass
harp
__________
Total
81
66
16
13
5
______________________________
(continued)
186
Instrument
No. of Musicians Injured

per Instrument
Others
accordion
conductor
__________
Total
1
2
______________________________
3 (0.7 percent of musician injuries)
The Ergonomics of Musical

Instruments
In Greek mythology, Procrustes invited his guests to sleep in his
bed, which he claimed was exactly the right size for each of
them. What he didnt tell them was the way in which he made
the bed t: by stretching his guests on a rack if they were too
short, or cutting off their legs if they were too tall. Like Procrustes guests, many musicians nd themselves trying to adapt
to an instrument, instead of adapting the instrument to themselves.
Some instruments, such as the piano or string instruments,
dont lend themselves easily to substantial physical modications. Yet breakthroughs can occur. On November 4, 1997, an
article appeared in the Wall Street Journal about a young
womans quest for a narrower keyboard. Hannah Riemann, a
ve-foot-tall, ninety-eight-pound piano teacher and pianist with
small hands, wrote to many companies attempting to persuade
them to make a piano with narrower keys so she could play
more comfortably. Almost all companies refused, citing high
production costs for little prot. Some even considered this an
inconsequential, ridiculous thought or an imaginary problem. When she was a youngster, her teachers assured her she
would grow into the standard keyboard, but she never did.
Apparently her problem is not unique. Yoshimo Nakada, one
of Japans most popular composers, and the Viennese pianist,
RSI and Musicians
187
Paul Badura, have voiced similar concerns. At one point, Ms.

Riemann learned that Kawai and Yamaha, Japanese piano manufacturers, listed narrow keyboard pianos in their catalogs, but
that they were only available on a limited basis in Japan. Finally,
she persuaded the German company that makes keyboard parts
for Steinway to make her a narrow prototype that slides into a
standard piano and lines up to strike the strings properly. Her
keyboard is about four inches shorter than the standard length.
(In the nineteenth century, octave width was 14 inch narrower
than it is today because the keys were 1516 inch narrower.) With
her new setup, Ms. Riemann can play anything, even Rachmaninoff, with greater ease.
Other, less dramatic attempts at ergonomic improvement of
musical instruments include Vladimir Horowitzs insistence on
traveling with his own Steinway, probably so he could have consistent keyboard touch. Other performers travel with their own
benches. But these are ergonomic luxuries usually denied to
ordinary musicians.
Violists are another group of musicians who have beneted
from ergonomic changes in their instruments. The viola is a
larger version of the violin, and an ergonomically decient cause
of injury. Here the credit goes to David Lloyd Rivinus for creating the Pellegrina Viola and the Maximilian Violin. He has lightened the instrument, adjusted string angle, made the instrument
asymmetrical for comfort, provided setup adjustments to accommodate different-size hands, changed tailpiece design, and added
extra sound holes. So far he has made twenty-seven violas, and
is increasing production on the violins. Mr. Rivinus can be
reached at riviola@blueskyweb.com or at 503-925-1628 (phone)
or 503-925-0410 (fax).
The double bass, the viola, the violin, the cello, and other
instruments can vary in size, so that choosing the right instrument is extremely important. Flutes, clarinets, oboes, bassoons,
French horns, and many other instruments can have their keys
modied to make them more comfortable. You dont wear onesize-ts-all shoes; a musician shouldnt have to play a one-sizets-all instrument.
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Beyond some modest changes in the form of the instrument,

the only practical way to avoid injury is to do what we are proposing for the nonmusicians in this book. There is a myth
among musicians that exercising may actually be harmful, making the musician muscle-bound and causing a loss of dexterity.
Nothing could be farther from the truth. The musician must
regard himself as an athlete, maintain proper posture and
strength, and use a proper ergonomic and biomechanical
approach. The less ergonomically adaptable the instrument, the
more the instrumentalist will have to pay attention to the biomechanical aspects of playing. Following is a brief discussion of
the various musical instruments, the problems they present, and
some suggestions to help overcome their difculties.
Piano, Harpsichord, Organ

In this group of instruments, physical conditioning and posture
need particular attention by the musician. Correct posture and
distance from the keyboard as well as light touch and properly
curved ngers are helpful in reducing soft-tissue trauma. While
doing her Ed.D. thesis, my associate Yu-Pin Hsu, an occupational therapist and musician, studied fty pianists and found
that postural misalignment was present in more than 90 percent
and thoracic outlet syndrome in 80 percent. Poor technique was
consistently observed.
Computer keys, electronic keys, and organ keys bottom out
to a hard surface with minimal cushioning, but piano keys dont.
Hitting uncushioned keys too hard is the equivalent of a ballet
dancer working on a concrete surface, instead of a sprung or
cushioned oor, which is now standard for dance stages (and
wrestling rings!). The organist has the additional problem of
playing on several keyboards and the need to work pedal bars as
well. This requires strength and coordination in the lower body
as it works with the upper extremities. The organ seat is often
not adjustable.
RSI and Musicians
Fifty Injured Pianists: A Research Project

In 1997, my assistant Yu-Pin Hsu devoted her Ed. D. thesis
to an analysis of factors contributing to the development
of RSI in pianists. First, she used examination data we
had recorded on 50 pianists ranging in age from 18 to 64
years, 29 of whom were males. The subjects consisted of
22 professional pianists, 8 teachers, 14 students, and 6
recreational pianists. Their common symptom was pain
related to their piano playing. Forty-seven pianists were
right-handed. Twenty-eight exercised regularly, 13
occasionally, and 9 never. In addition to pain, 9 reported
weakness and fatigue, 6 had tingling in the hands, 5
had numbness, and 4 had tightness and stiffness in the
arms and hands. One person lost nger coordination,
and 1 had tremors. They practiced an average of 3.6
hours a day, with a range from a few minutes to 8 hours
a day.
Dr. Hsu set about videotaping all of these musicians as
they played a standard repertoire. Aberrant postures,
awkward positioning, and other potentially harmful technique idiosyncrasies were recorded. These are the results
of her observations:
Fingers: Hyperextension of the pianists ngers was
demonstrated in 46 of 50 subjects. Hyperextension is
known to be an inefcient way to use the ngers (see
chapter 9).
Wrists: Awkward positioning of the wrists contributes
to injury by overworking the forearm muscles. Forty-seven
people showed excessive wrist ulnar deviation. Ten
showed radial deviation. Eight either exed or extended
their wrists excessively. Twenty-six showed wrist motion
unnecessary to carrying out their musical repertoire.
Forearms: Elbows held too close to the body caused
two main problems: forcing the pianist to compensate by
going into ulnar deviation, and limiting range of motion.
Twenty subjects held their elbows too close to the body.
Two people held their forearms in excessive supination,
and 2 played in hyperpronation.
Other upper extremity activities: In addition to playing
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the piano, other upper extremity activities were affected

negatively, including a tendency to drop objects.
Diagnostic data: Postural misalignment and RSI were
found to be the main problems in 49 subjects. Forty-three
had protracted shoulders. Head and neck problems,
scapular winging, and other upper and lower back problems also were common.
Harp
There is little one can do ergonomically with a standard harp
except to use a smaller or a larger version. In my experience, the
main problem for harpists is poor physical conditioning combined with lack of shoulder and upper arm involvement in
plucking strings. Excessive wrist motion in ulnar and radial
deviation and poor position, particularly as the hand is placed in
dorsiexion, lead to forearm muscle overuse, particularly when
combined with the common postural problems seen in RSI.
Violin
Biomechanically this instrument is a challenge, but certain
adjustments can make playing the violin a lot more comfortable.
It is important to be sure that the chin rests and shoulder rests
are suitable to the length of the players neck. A long neck will
require the shoulder rest to be set high. There are many different
types of shoulder rests, but nearly all of them do not ll what I
call the forgotten space just under the clavicle or collarbone.
When this forgotten space is not lled, the violin will angle
forward and tend to fall off the shoulder. The musician compensates by gripping the neck of the violin tightly with the left
thumb and pressing down with his neck. This tightening of the
thumb also makes it harder to ex and extend the rest of the
ngers and can lead to injury. An easy solution is to place a soft
RSI and Musicians
191
sponge in the form of a wedge, which lls the forgotten space

and stabilizes the instrument. This should set the body of the
violin at about a thirty-degree downward angle from the horizontal. This enables the bow to work the strings steadily and
more horizontally. With the help of gravity, bowing is smoother,
and to that extent the quality of the music is improved. The chin
rest may be more comfortable if centrally placed over the tailpiece of the violin, so that the musician faces forward. Relieving
the pressure on the neck will additionally prevent the common
chronic inammation of the skin know as ddlers neck.
Viola
The viola is essentially a bigger violin and can cause problems
because of its size. The viola should be chosen with consideration of both the players size and the sound quality of the instrument. Good instruments 16 or 161 2 inches in length are
available, while the larger 17-inch instrument, which might be
chosen for its sound, has greater potential for injury. A sponge
wedge under the forgotten space below the clavicle is as useful
for the viola as it is for the violin. An ergonomic viola has been
created that reshapes the body of the viola in an asymmetrical
form, placing more of it away from the neck to allow more freedom of movement. (See gure 41.)
Figure 41. The modied Pellegrina viola (left) and the Maximilian violin
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Cello
Proper positioning of the cello certainly demands good physical
conditioning in the upper body and specically in the entire
back. Low back problems are common among cellists, often
because proper seating is not given enough attention. Positioning may also be modied by the use of a bent oor pin, such as
the one designed by master cellist and conductor Mstislav
Rostropovich. The atter conguration of the instrument, sometimes with the use of a bent pin, allows the bow to be assisted by
gravity, improving the quality of the music as well as enhancing
comfort. If the pegs tuning the string tension get in the way
of the left side of your head, they can be eliminated by
substituting a keyhole and removable key arrangement similar
to that of a clocks winding mechanism. Cello width also should
be taken into consideration when choosing an instrument. An
occupational illness known as cellists scrotum has been
described as the result of the instrument rubbing the crotch of
the musician.
Double Bass
This is an instrument whose huge size poses ergonomic problems even in transporting it. Rather than using a shoulder strap,
many musicians push it around on a large wheel attached to the
case. The instrument sits on a pin and is played by either plucking or bowing the strings. An instrument this large requires the
musician to be in optimal physical condition to avoid injury.
Larger body size is helpful, but not entirely necessary. There
are various size instruments that can be tted for comfort for
people of different sizes and shapes. The most common problems Ive encountered with double bass players are postural
misalignment, neurogenic thoracic outlet syndrome, and low
back syndrome.
RSI and Musicians
193
Guitar
Classical guitars are light but unwieldy and are somewhat difcult to stabilize. A good, wide shoulder strap can help. Guitars
may be held in a variety of positions while sitting or standing,
which further complicates playing the instrument. When sitting,
the classical position, with the body of the instrument centrally
located and the left leg elevated, is ergonomically efcient, since
it allows both wrists to be held in a neutral position. This is what
we suggest when treating injured players, even those using
heavy rock bass guitars. In the sitting position, various devices
from sponges to rubber mats are used to stabilize the body of
the instrument on the left knee (for a right-handed player). An
A-frame holder for the thighs also is available. Finally, lighter
strings, in the 9- to 10-gauge range, offer less tension and are
useful in the early stage of retraining an injured player. Electric
guitars and bass instruments have problems relating to both
weight and positioning. In the standing position, the instrument
should be centered and held low enough so that both the right
and the left wrist can achieve neutral positioning.
Percussion
The percussion instruments usually involve vigorous physical
activity that you might think would keep the musician in good
physical shape. And in fact, we see percussionists less often than
most. Nevertheless they can get hurt if their biomechanical technique is poor. The most common aw in drummers was presented by A. P., a self-taught rock drummer who was able to
pursue his career without any problems until he hit his midthirties. As aging affected his posture, he began to notice diminished
strength in his arms coupled with pain during and after a concert. When I rst examined him I noticed, apart from his roundshouldered posture, that he was gripping his drumsticks very
tightly, locking his shoulders in place, and essentially using only
194
wrist motion to perform. Even though he looked quite strong, he

was essentially losing the considerable strength and movement
available in his upper arms and shoulders. I have seen this not
only in drummers but also in injured tympanists, xylophonists,
and vibraphone players, among others. An analogy for this wristonly technique would be a baseball pitcher trying to throw a fastball by icking his wrist. When A. P. saw the videotape we made
of him at the drums, he was shocked. He never realized how
badly he was limiting his upper body movement. We began his
retraining by having him repeat the motion of drumming while
integrating shoulder movement into his stroke. Joe Morello, a
master drummer and teacher formerly with Dave Brubecks
group, gave me this tip: use your upper body the same way you
would if you were slapping your thighs. We built on this concept,
and soon after stretching and strengthening exercises, postural
retraining, and some ergonomic guidance, A. P.s strength
increased enormously, and shortly thereafter, an almost magical
transformation took place. A. P. is again regularly performing
dynamic drum solos for his rock groupand without pain.
Flute
This instrument can be extremely injurious. Luckily, the ute,
along with several other wind instruments, is eminently
amenable to substantial changes to make it more comfortable to
play. Most of the factory-produced instruments simply do not t
most hands. Some work I did with a utist is a good example of
the ways in which an instrument can be modied.
A young woman came to see me because, while she had been
playing the ute for ten years, it was nevertheless very uncomfortable, even painful, for her to continue to play it. After a complete
examination it was obvious that while she was in good general
health, she did have congenital shortening of the fourth and fth
ngers of both hands. I placed her in a biomechanically correct
position, and took measurements between the keys she could not
reach and her ngers. I carefully placed the ute on a copying
RSI and Musicians
195
machine and drew the new key conguration with Wite-Out. I

then took the instrument to a technician, who soft-soldered new
extensions as in the diagram. When the patient returned, she was
tted with a temporary support based on the web space between
the thumb and index nger until she got used to her new position
(see gure 42). A crutch to widen her grip was placed on the
body of the instrument. With minor adjustments to increase comfort, she was eventually able to play comfortably.
Another technique recently used (with the help of Vera
Wills, a musical ergonomist) was to attach adhesive-backed felt
on the keys for the musician to try while undergoing retraining.
In this case, a utist who had quit the stage was able to return to
performing after these modications were made permanent.
Problems with the ute relate particularly to the left hand,
where the wrist is forced upward into dorsiexion and radial
deviation, while the index finger is further extended at the
knuckle and then is severely exed at the second joint. In addition, the third, fourth, and fth ngers often have to be stretched
or extended to reach the keys. The stress put on muscles and
Figure 42. A modied ute
196
tendons by these positions is enormous and can lead to severe

problems, especially in people with small hands or short ngers.
Modications like the ones we describe here put the wrist in a
neutral position and allow the other ngers to be comfortably
curved, offering a relaxed posture and better control. Other
devices, such as support stands for the whole instrument or a
curved-neck ute, can be useful in overcoming some of the
ergonomic problems faced by the utist. The approach to modifying use of the piccolo is similar but less often required.
Keeping the utist facing forward while playing is worth the
retraining effort to diminish neck twisting and bending for both
increased comfort and related postural problems.
Occasionally utists will develop focal dystonia in their ngers or embouchure muscles. Focal dystonia, also known as
writers cramp, is one of the worst occupational injuries a musician can face. When it occurs, years of study and a livelihood
can be put in peril or completely extinguished. Usually there is
severe emotional upset associated with this catastrophic event.
There are many ways in which musicians affected with focal
dystonia cope with their illness. A utist with dystonia of the
muscles surrounding the mouth (the orbicularis oris) might be
able to switch to an instrument with a different embouchure,
such as a clarinet. This ability to function with a different instrument tells us that focal dystonia is task-specic. A violinist with
focal dystonia might attempt to change the position of the
instrument and undergo biomechanical retraining to attempt to
regain control of his or her ngers. In my experience this is possible but difcult. In one instance, a violinist I saw who had
developed dystonia of the fourth and fth ngers of the left
hand was offered biomechanical retraining, but instead chose to
switch his career to conducting. This is yet another positive way
of coping. This actually happened to Robert Schumann, a brilliant pianist of the nineteenth century who became a conductor
and composer after struggling with his loss of nger control. In
his desperate attempt for a solution he created devices with
springs and rubber bands as well as engaging in futile exercises
that only seemed to make things worse.
RSI and Musicians
197
Pianists seem to be the most frequent victims of focal dystonia, although this may be because it is the most frequently
played instrument. It was the technique of one famous pianist
that resulted in her injury. She had very long ngers that played
in a at, extended position. Other awkward positions also were
part of her technique. Over time she developed a dystonia of the
fourth and fth ngers of the right hand, which would curve
inward as she played, causing her to lose control. Poor technique
is more likely to occur in less experienced pianists but also can
occur in seasoned professionals. Sometimes the poor technique
of a child prodigy, which the teacher might be afraid to correct,
can result in injury later.
This pianist realized she could no longer play the dramatic
romantic pieces in her repertoire and regretfully retired from the
concert stage. She became profoundly depressed and went into
virtual seclusion for a number of years. Desperate, she sought the
help of medical professionals, all of whom agreed on the diagnosis of focal dystonia, but offered no denitive help. Undaunted,
she searched for someone who might offer some retraining help.
She nally found a teacher who specialized in the retraining of
injured musicians and who set about modifying her technique.
One of the rst things the teacher suggested was changing her
repertoire. He moved her on to music that was simpler, avoiding
complex chords and scales. Gradually, with training exercises, she
slowly began to improve. She was then taught additional tricks,
such as slowing her pace and using her left hand to compensate
for notes that her fourth and fth ngers could no longer reach.
She was also shown that by extending and holding the fourth and
fth ngers, followed by twisting the wrists and coming down on
the keys in this fashion, some function of these ngers was possible. Her physician suggested that a certain surgical procedure also
might be helpful. Here the plan was to sever the brous connection between the extensor tendons of the fourth and fth ngers.
It had been noted that when either of these ngers was exed, it
would pull the other nger down with it. The operation, a simple
one, was performed and gave the pianist slightly more freedom,
since now it was only the fth nger that curled under because of
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the dystonia. After several years of hard, painstaking work, the

pianist was able to return to the stage. In this case, sheer will and
determination allowed this person to at least partly conquer a
devastating illness.
Clarinet, Oboe, French Horn,

Trumpet, and Bassoon
Clarinets and oboes are ergonomic nightmares. This is primarily
because these instruments hang on a thumb hook, which upsets
the total dynamic of nger action, especially if it is improperly
placed. Ideally the clarinet or oboe should be unloaded from the
thumb. Dr. H. J. H. Fry, a hand surgeon in Australia, has
designed a neck strap and shoulder harness that, when coupled
with a post that rests between the instrument and the chest,
removes the need for a thumb rest. If a thumb rest is used, then
the thumb should be in an anatomically comfortable position
and the key lengths should be modied so that slightly curved
ngers come comfortably into contact with the keys. The oboe
has additional ergonomic problems for musicians who create
their own reeds. This additional forearm and nger work can
contribute to the development of RSI. The high pressures created in the oral cavity when playing the oboe have been
reported to cause soft-palate paralysis.
Another ergonomic burden of the double reed player is the
process of making reeds. Although reeds can by purchased
ready-made, many professionals prefer to make their own.
Reeds are made from a bamboolike cane called apundo donax.
The cane is slit lengthwise in three pieces. This is followed by a
meticulous set of steps that place great strain on the ngers,
hands, and forearms. These steps include gouging and shaping
the cane with a razor, tying it to a tube, and hoping it will produce a pure tone. Obviously, the injured oboist will have to nd
alternatives to making his or her own reeds.
Ergonomic principles apply to the French horn, where the
levers are often not long enough. Soldering extensions to the
RSI and Musicians
199
levers can alleviate this problem. On the left hand, the fthnger open ring may be improperly placed and should be correctly positioned for this nger. A knee holder consisting of a
sponge attached to the thigh will prevent discomfort from the
notch that the horn usually presses into the thigh.
Both French horn and trumpet players can sustain complete
or partial tears of the muscles surrounding the mouth. This is
often referred to as the Satchmo syndrome, which is the result
of playing the instrument for prolonged periods while hitting
high notes. The French horn has a particularly narrow rim on
the mouthpiece, which may need to be changed. Surgical repair
is possible if long periods of rest do not cure it.
The bassoon is another instrument that can cause both
right- and left-hand problems, requiring key modication. It can
be played suspended or with a oor spike, although some bassoonists claim there is a loss of exibility with the spike and prefer the shoulder strap.
Percussion
Most of the drummers and other percussionists (vibraphone,
xylophone, etc.) get into difculty for two principal reasons.
First, they all play physically demanding instruments, and the
musicians are often in poor shape and may develop low back
problems. Second, they are gripping their sticks too tightly and
using only their wrists instead of their whole arms and shoulders
in an integrated fashion.
Problems in the Orchestra

Seating
Very little consideration is given to proper seating for orchestra
musicians or, for that matter, nonorchestra players such as the
200
soloist. This is compounded by the fact that orchestras often

travel, and seating varies in different halls. Seating should be stable, cushioned, and, ideally, suit the height of the musician.
Sound Control
Hearing problems are not an infrequent occurrence for orchestra
as well as rock musicians. Attempts have been made to use plastic shields to protect certain orchestra musicians, but this is
rarely done. Standard earplugs distort the nuances of sound that
musicians need to hear to play in synchrony with others. A practical solution has been custom-tting musicians with noise attenuators, specially tted devices that are inserted in the ear and
diminish the sound level but dont distort the quality of the
music. All musicians should have periodic hearing tests.
Stage Fright
In a survey of over two thousand musicians conducted by the
International Congress of Symphony and Orchestra Musicians
(ICSOM), stage fright or performance anxiety was high on the
list of health problems. Musicians have been known to cope
with this by taking propanolol, a beta blocker, to quell their
symptoms. It is advisable for musicians with this problem to
seek professional advice.
Playing a musical instrument, although you might not have
thought so, can be a dangerous profession. Evaluation of an
injured musician proceeds along the same course as that of any
other person with a work-related upper extremity disorder. In
examining injured musicians, it is critical to observe them playing their respective instruments; videotaping is very helpful in
this regard. Modications of ergonomic and biomechanical factors are extremely important with musical injuries. Therapy
proceeds along the same lines as for any RSI patient.
13
Other Causes
of RSI
A multitude of causes unknown to former times are now

acting with a combined force to blunt the discriminating
powers.
William Wordsworth (17701850)
In addition to those already mentioned, many other workrelated upper extremity activities can lead to RSI. Although the
sources of injury may differ, RSI is a common nal pathway. In
many cases these activities are carried out in addition to other
repetitive functions, such as computer use. The complaints in
this group are like those of many other RSI sufferers. The culprits are similar: repetition, sustained activity, awkward positioning, deconditioned state, poor ergonomics. The following
examples by no means complete the roster of risky professions
but will give some idea of the range of professions at risk.
RSI and Court Stenographers

Anyone who has been to court or seen TV or movie court
scenes has noticed the ever-present court stenographer busily
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202
working at a small machine near the judges bench. As the operator plies the keys of the machine, a sheaf of encoded paper
pops up and drops into a box at the back of the machine. Later
this will be decoded and turned into court testimony. At one
time, court reporting was done by hand. The stenograph
machine was invented to increase speed, and was rst used and
gradually perfected in the late 1800s. An alternate version was
developed for ofce secretaries taking dictation. As we have seen
with the typewriter and computer, improvements were made not
so much for comfort as for efciency. This type of phonetic
shorthand enabled the user to record 200 to 225 words per
minute, more than double the speed obtainable with a typewriter. Stenograph machines as presently used come in several
models, including one that can connect to a computer to provide
a real-time transcription of testimony.
All of these machines have a similar setup consisting of
twenty-ve keys: thirteen of them for consonants and four for
vowels. A syllable can be recorded with a single stroke. The ngers of the left hand generally type the beginning sound, which
is usually a consonant, while the thumbs hit vowel keys. The
right hand can type the syllables end sound. Repetitive strain
injury is not an uncommon result of this work.
Ergonomically, these machines are usually placed horizontally on a stand, causing the operator to keep the wrists in extension. One of the ergonomic modications suggested is to secure
an adjustable stand, now available, that allows the machine to be
tilted downward, away from the operator so that the wrists are in
a neutral position. The most comfortable posture for the operator
is to straddle the machine so it is approached central to the body.
As I looked through some of the manuals for older stenograph machines, I found instructions for a ladylike posture for
women. They were advised to position themselves sideways.
This would cause their bodies and necks to be twisted to the
right or left, a recipe for muscle imbalance leading to neck and
shoulder problems. Even if such positioning is avoided, operation of the stenograph machine encourages the same kind of
eventual postural misalignment seen with computer users or
Other Causes of RSI
203
pianists. Posture deteriorates over time. The keys of the stenograph machine have a soft touch but require more use of the
thumbs than the typewriter or computer keyboard, where
thumb use is generally limited to the space bar.
The court stenographer is also often asked to work over sustained periods of time, increasing the risk of injury. Very few
stenograph users consider that they are engaged in an athletic
activity that requires postural training and strengthening exercises
to avoid injury. We have had to retrain a number of court stenographers to modify their technique. A neutral wrist position and
slightly curved ngers with short nails are part of this process. In
addition, the stenographer may need to lighten his or her touch.
Court stenographers often work long hours in the courtroom
but then must later transpose the phonetic coding into court testimony using a computer. Many of these people are in chronic
pain and risk partial or permanent disability. While serving as an
expert witness, I have been approached many times in the courtroom by individual stenographers who were having their own
problems with RSI. I have also testied for several court stenographers at workers compensation hearings. A few of my court
stenographer patients, despite our best efforts, have had to leave
what for them was a lucrative but punishing profession.
RSI in Garment Workers

Dr. Robert Harrison, clinical professor of medicine at the University of California in San Francisco, and Jacqueline Chan,
M.S., M.P.H., of the California Department of Health Service,
have studied this population and created a model partnership
between health services and worker advocates. Their goal was
to lessen injury in a major industrial area. Worldwide clothing
production is approximately a $335 billion business. Seventyve percent of 11 million workers are women, about 793,000 of
whom work in the United States. Dr. Harrison has described the
main problems seen in these workers. They include generally
unsafe conditions in many unlicensed shops, long hours with
204
few breaks, no benets, no control over work, cultural and language barriers, and workers fear about reporting injury. All of
these factors point to a high likelihood of injury. Indeed, sewing
machine operators have signicantly more symptoms of musculoskeletal distress than other garment workers. In one study of
six shops, 91.9 percent of operators experienced symptoms.
Eighty-seven percent complained of neck pain, 75 percent
reported symptoms in the back and hips, 35 percent complained
of pain in the hands and wrists, 35 percent noted pain in the
legs, and 28 percent had pain in the arms and elbows.
The ergonomic problems faced by these workers included
nonadjustable chairs, being forced to work in various awkward
postures, repetitive pinching to push cloth through the machine,
contact stress from pedals and levers, the requirement for a rapid
pace of work, and no rotation of tasks. Some of the ergonomic
solutions include table extensions with teacup holders, improved
foot support, adjustable chairs with wedge and lumbar supports, and knee pedal cushions.
Because injuries among garment workers can be severe,
patient care interventions were developed in the California project. These included a free clinic, clinical exams, physical therapy,
massage and exercise classes, and ergonomic instruction.
Unfortunately, the relation of their work to their injury is
generally not understood by these workers. Fear of job loss and
a feeling that pain is an integral part of the job are also factors
that thwart recovery.
Injuries among Dental Practitioners

and Dental Surgeons
Dentists and dental practitioners are in a high-risk profession for
RSI and are often the victims of severe injury. The same kinds
of problems are encountered by certain medical specialists,
including surgeons and ophthalmologists (see chapter 11), who
often are forced to work in awkward positions performing ne,
demanding work using the arms and ngers. According to Dr.
Other Causes of RSI
205
Robert Goldberg, associate clinical professor of occupational

and environmental medicine at the University of California in
San Francisco, risk factors in this eld involve posture, upper
extremity positioning, grip, repetition, force, and vibration.
Injuries can be severe, so that the same rules of prevention we
have discussed related to body conditioning and strengthening
apply here.
Some of Dr. Goldbergs suggestions include the following:
Patient positioning is important. While the typical patient
position is slightly higher than horizontal, it would be better
to place the patient in the full horizontal position, so that the
practitioner is perpendicular to his or her patient and does not
have to reach over the patient from an awkward position. In
this fashion the practitioner can sit comfortably with good
back support in an adjustable chair with feet rmly planted on
the ground.
Chair height should be adjusted so it is neither too low, forcing the practitioner to bend over the patient, or too high, putting him or her in a cramped posture with a twisted neck. The
alignment of the practitioner is also important. Sitting
sidesaddle and twisting the body while working produces
gross misalignment of the body.
Proper alignment results in the practitioner gaining full back
support from the chair with feet rmly planted on the ground
in straight body alignment. Footrests can be helpful in attaining good alignment. Another useful intervention is a magnifying loupe, which keeps the practitioner from crouching over
and encourages good posture.
Instrument use, design, and balance are important. When
possible, instruments should be held with the wrist in a neutral position. As with writing instruments, increased barrel
width can be more comfortable. When instruments are
attached to a cord, the length should be such that the practitioner doesnt ght the cord while working. Finally, gloves
that are too tight can hamper hand activity and cause fatigue.
Although these are general suggestions, each practitioner
206
armed with basic ergonomic information needs to adjust the

workstation according to individual body measurements and
space type of work.
Sign Language Interpreters

Sign language interpreting is known as a high-risk occupation
for RSI. Patients I have seen can become seriously injured with
a variety of upper body disorders similar to what might be seen
with computer users or other persons engaged in repetitive
activity.
Signing is a physically and mentally demanding profession.
Following an intensive and difcult course of training, interpreters submit to an examination to be certied by the National
Association of the Deaf (NAD). They may also gain and submit
to a code of ethics promoted by the Registry of Interpreters for
the Deaf (RID). Some work through agencies, while others freelance. Similar certication organizations exist in many countries
of the world.
Sign language interpreters are under constant stress as they
work. They must have a high level of awareness as they strive
for absolute accuracy. Like the computer user, whose very art of
sitting at the keyboard may cause the body to tense, the interpreter tends to tighten his or her entire body when beginning to
work. The various positions of the hands and arms include vigorous use of the ngers and forearms in particular.
The hand is opened and closed rapidly. This is combined
with supination and pronation at the elbow, ulnar deviation,
radial deviation, extension, and exion of the wrist. If the forearm and hand muscles are held tightly, then muscle groups will
tend to work against each other and injury will occur. The head
of the signer is often thrust forward and the shoulders and neck
are held tightly, which can lead to the familiar findings of
postural misalignment possibly leading to neurogenic thoracic
outlet syndrome.
Good ergonomic rules for the signer will often depend on
Other Causes of RSI
207
the preparations made by those requesting the service. The sign

language interpreter would do well to discuss these issues before
beginning work. The signer should be provided with a good
straight-back chair without armrests. When the signer is seated
and working, there should be no obstruction between him or
her and the target audience. Good lighting is essential. In the
case of a slide show or theater presentation, the signer should be
in the beam of a spotlight, and any glare from open windows or
direct sunlight should be eliminated.
Biomechanical retraining may be necessary to allow the
signer to move in a more relaxed fashion, avoiding exaggerated
or excessive motion. Stretching and strengthening upper body
muscles are critical to protect against injury. Signers should not
work more than one-half to three-quarters of an hour at a stretch
without a break. If the session is more than one and one-half
hours, an alternate signer to assist would be necessary. Various
sign language organizations specify the work limitations in their
work protocols.
There are, of course, a whole host of other professions
where upper body injuries can occur. Think of the artist, the
butcher, the poultry worker, or the cook. A sherman from
Alaska who injured himself cutting the heads off salmon recently
wrote to me. Similar injuries often occur in these different professions and should be treated similarly. The keys, as we have
indicated, are a complete physical exam done by a knowledgeable provider, followed by biomechanical and ergonomic intervention under the supervision of a qualified physical or
occupational therapist. A continuing conditioning program completes the picture for all upper body workers.
14
Beating RSI: A Five-Step
Protection Plan
Wouldnt it be great if you could avoid suffering from RSI for

life? It can happen if you take the knowledge youve gained
reading this book and put it into action. There are obstacles to
overcome even if youve undergone successful treatment.
Relapses are not uncommon, especially if you revert to your old
ways of doing things. These can be minimized and eventually
eliminated as you learn how to cope with the illness. Keep in
mind that with RSI you are recovering, not necessarily recovered. What follows is an outline of the steps you need to follow
toward your goal of beating RSI for life. It wont be easy, but it
is certainly worth the effort.
Step 1: Examine Your Life

Assess your risk for injury by taking a good look at your activities both at work and elsewhere. You might nd it useful to write
down each of your daily activities, along with time spent and
degree of intensity. The list can give you a good idea of your
risk prole. Think about whats going on in your life every day
and ask yourself questions: Does your boss subject you to
long hours, short deadlines, and binge work? Do you do this to
209
210
yourself? Do you work more than two to four hours at a time at

a computer? Do you use a mouse, laptop, phone, or other
equipment intensely? Even pushing and pulling on ling cabinets can lead to backaches and postural problems and can contribute to RSI. Are your chair, workstation, and other
equipment sources of obvious discomfort? Is your life full of
enormous repetitive chores and responsibilities that put you
under stress? Are you having trouble sleeping or eating? Has
your work affected your sex life? Do you feel depressed?
In doing this self-assessment, dont forget to recognize the
potential for injury from what you do when you are at home.
While such activities may be a symptom of injury, they can also
contribute to your problem. Dusting, vacuuming, washing oors
and dishes, gardening, and writing can all tip you over the edge.
Certain sports can contribute to injury. Golf, tennis, basketball,
and skiing can all enhance risk of injury.
If you think about these factors as you examine your list,
you may notice that you are doing too much. This self-appraisal
is the rst step in helping you become informed about what is
necessary to reach your goal.
Step 2: Get a Physical Evaluation

Self-evaluation is difcult and not as objective as the opinion of
a qualied professional, who may detect things you dont know
you have. To start, learn something about how you are put
together. Ive tried to help with this by discussing some anatomy
in chapter 1. This will enable you to understand what the physician or therapist is doing. Youll know why you are receiving certain medications or which group of muscles needs work and
why. Although RSI is sometimes described as a musculoskeletal
illness, it also involves nerves, muscles, tendons, ligaments, and
vascular structures. Taking the trouble to learn about your own
anatomy will help you understand how that information relates
to other steps in this program.
Physical and occupational therapists are trained to evaluate
Beating RSI: A Five-Step Protection Plan
211
your musculoskeletal system. They have to be able to do this to

correct specic problem areas. First they would look for derangement of posture. If you have been working for years slumped
over a desk, your posture is bound to deteriorate. These changes
mark the beginning of a continuing process that can eventually
result in RSI even before age thirty. The people I usually see in
my practice are relatively young, otherwise healthy, but nevertheless disabled. This paradox of a healthy-looking patient with
severe physical limitations is one cause of the abundant skepticism of health care professionals. Certain illnesses, such as type II
diabetes and obesity, need to be ruled out as contributing causes.
Recent research has shown that osteoarthritis may be related to
long-standing RSI. One theory is that tightened muscles place
extra strain on joints or tendons, producing wear and tear.
Step 3. Plan Prevention and Cure

Assuming you now have some basic knowledge about where
you stand, the next step is to begin to take proper care of your
body either to prevent injury or to care for an existing injury.
These measures have to include taking care of workstation deciencies, problems at home, and other issues relating to your
physical activities.
Once you have found the right treatment team, you can
begin working with the physical or occupational therapist, who
can guide you in a carefully orchestrated program of stretches
and exercises. These are outlined in chapter 7. Now your job is to
do the stretches and exercises at home under the guidance of
your therapist. I cant overemphasize the importance of continuity and consistency in performing exercises and stretches on
your own. This is where people who have improved get hung
upthey stop the exercises because they think they dont need to
do them anymore, or because theyre simply bored with them. If
you become too busy to do them, this may be a sign that you are
headed for a relapse. Daily exercise accomplishes several things.
It enables you to defeat the process of postural deterioration,
212
which progresses insidiously over time and leads to RSI. Stretching and strengthening muscles improve blood supply to all soft
tissues, the key to both avoiding relapse and preventing problems
to begin with. The neuromuscular therapeutic program will
emphasize upper body work, but you shouldnt neglect the condition of your lower back and extremities. Problems below can
affect the upper body, too, because muscles that are deconditioned can affect the function of muscles elsewhere. These concepts are discussed in chapters 7 and 11.
If you are having a hard time getting started because of
advanced or painful injury, you also may need pain medication.
This will allow the therapist to work on your soft tissues and
allow you to get started cautiously with your exercises. If you
are depressed you may need medicine, and some antidepressants also are helpful in controlling pain (see chapter 5). A psychiatric evaluation is advisable. Once you begin this process,
youre on your way to both treating your RSI and diminishing
the likelihood of relapse. The next step involves applying your
knowledge of ergonomics to what you do.
Step 4: Pay Attention to Ergonomics

Fit the equipment to yourself, not yourself to the equipment. We
should not be made to put ourselves in awkward positions to
accommodate the instruments we work with. It is critical to
embrace this concept because it will add to the likelihood that
your recovery and RSI prevention will be permanent.
Changes you make in your workstation or your musical
instrument can play an extremely important role in keeping you
out of trouble. They may even be enough to make a dramatic
impact on recovery. This may require investing in new equipment, such as a chair, pullout tray, keyboard, or mouse. Musicians might have to modify their instruments or make other
positional changes. We have looked at some of these issues in
chapter 11. By doing this youve added an additional layer of
protection against injury.
Beating RSI: A Five-Step Protection Plan
213
Another important component of ergonomics is what might

be called intrinsic ergonomics or biomechanicsthe ways in
which you use your body to perform work tasks. To correct
biomechanical deciencies that, because of awkward positioning, place a strain on soft tissues may require the help of a specialist in interpreting and eliminating incorrect movement
patterns. The trick is to use your body efcientlyin essence,
getting more miles to the gallon. Many, but not all, physical and
occupational therapists are adept at evaluating movement. If you
can nd someone skilled in this area, it can be very helpful.
Step 5: Work the Health Care

System
Whether you work for a company that provides insurance or
carry your own policy, you may nd it hard to get payment for
the help and attention you need. A work-related injury usually
puts you under the care of a workers compensation carrier.
Workers compensation insurance benets vary from state to
state, and dealing with the bureaucracy can be onerous. As a
result, many people choose not to get involved unless the injury
is very serious. A recent study reported that only 11 percent of
workers actually used workers compensation for an injury.
Most simply did not seek care or preferred to use their own care
provider. Finding the right health care providers who understand RSI is not easy. The subjective nature of your pain and
other symptoms can lead to skepticism and resentment by your
employer, fellow workers, your physician, and your insurance
carrier. This is the most frustrating part of the battle for care and
attention. Of the patients I have seen, about 60 percent were still
working despite pain and other symptoms. If you have to work
under these conditions it can lead to a progression of symptoms
and condemn you to an uncomfortable and stressful life.
One of my patients who was a nancial translator in a bank
was pushed to the limit by her employer because her skills were
unique. Eventually she became seriously injured and was forced
214
to leave her job. She came to see me, and after her diagnosis was
given an exercise and stretching program for her repetitive strain
injuries, which included neck mobility problems relating to thoracic outlet syndrome as well as postural misalignment. Seen in
a normal social situation, it would be difcult to determine that
she was ill. She continued to exercise and stretch but could not
get the sustained and progressive input of her physical therapist
because her insurance company cut off her benets despite the
fact that she was unable to work a full day. Her employer had no
alternate position for her. She pursued her attempts to reinstate
her benets. After much travail she obtained a disability award.
Soon afterward, however, she had to face an appeal by her insurance carrier which included seeing an independent medical
examiner, who concluded that he doubted the existence of her
disability. This sort of frustration and uncertainty is not uncommon and is a great source of stress.
It is difcult to obtain an effective answer to this problem
except to urge patients to continue to ght for their rights. You
may need the help of a lawyer or other professional to advocate
for you.
What else can you do to make it easier to prevent RSI or
improve your condition? Remember that you are essentially an
athlete who has to remain in shape to work safely. Weight loss,
proper diet, exercise, stretches, recreation, and rest breaks can all
help you successfully manage your RSI program. Doing these
things consistently for a lifetime is really a challenge, but its certainly worth the effort.
Glossary
acupuncture The Chinese method of inserting needles into specic

areas of the body to relieve pain.
acupressure The process of pressing specic areas of the body to
relieve pain.
accommodation The ability of the lens of the eye to adjust for various
distances; this ability diminishes with age.
acuity The clarity or clearness of vision.
Adsons test This is used to determine the presence of blood vessel
compression in thoracic outlet syndrome by placing the head in specic positions to see if pulses are lost or diminished.
Allen test A clinical test for blockage of the ulnar artery or radial arteries at the wrist.
allodynia Occurs when a stimulus such as mechanical pressure produces pain when there should be none.
alpha receptors Alpha adrenergic receptors respond to adrenaline
(norepinephrine) and certain blocking agents.
ANA See antinuclear antibody.
anomaly An abnormal anatomic structure not typically present.
antidepressants A group of medications used to treat depression and
other psychological problems. Two principal groups are the tricyclics
and the selective serotonin reuptake inhibitors (SSRIs).
antinuclear antibody (ANA) A lab test used for the detection of various connective tissue diseases such as lupus.
215
216
Glossary
anxiety An unpleasant emotional state that is an anticipation of real or

imagined danger.
arcade of Frhse A brous tunnel that is a portion of the supinator
muscle at the elbow. Present in 30 percent of adults, it is implicated in
the compression of the radial nerve (radial tunnel syndrome).
autonomic dysfunction Abnormality in the involuntary or autonomic
nervous system. A common nding in persons with RSI on physical
examination.
autonomic nervous system (sympathetic and parasympathetic nervous system) The portion of the nervous system concerned with regulating cardiac muscle, smooth muscle, and glands that are not under
your direct control.
binocularity The ability of the eyes to fuse images and create one
three-dimensional image.
biomechanics The application of mechanical laws to living structures.
It is the investigation of how we move.
brachial plexopathy See brachial plexus or thoracic outlet syndrome.
brachial plexus A network of nerves that unite in the neck area, tying
the front portion of the last four cervical nerves to most of the rst
thoracic spinal nerves (see gure 15). The brachial plexus forms several branches as it leaves the neck. Compression of the brachial plexus
or its branches is called brachial plexopathy or neurogenic thoracic
outlet syndrome.
bone scan A technique using radioisotopes to detect abnormalities in
bony tissue.
calcium channel A protein channel that is permeable to calcium and
sodium ions that are found in cells. Calcium channel blockers are
used in the treatment of hypertension.
carpal tunnel syndrome Median nerve compression at the wrist often
associated with repetitive motion and other causes.
carrying angle The xed angle at the elbow between the humerus and
the ulna bones. Women tend to have larger carrying angles than men
do.
causalgia See complex regional pain syndrome (CRPS).
CTD See cumulative trauma disorders.
cervical radiculopathy A disease of the root of a spinal nerve, especially that portion of the root between the spinal cord and the vertebra
that forms the canal that the spinal nerve passes through.
Glossary
217
clavicle (collar bone) Combined with the rst rib, it forms a tight
space where brachial plexus nerve compression can occur.
complex regional pain syndrome (CRPS) A painful immobilizing
syndrome linked to the sympathetic nervous system, of which there
are two types: Type 1, formerly RSD, and Type 2, formerly causalgia.
Symptoms of both types are similar and consist of burning pain,
swelling, stiffness, and skin and bone changes in its later stages.
computer vision syndrome (CVS) Eye problems relating to the use
of the computer such as dry eyes, eye strain, headache, and blurred
vision.
computerized tomography (CT scan) A computer-assisted X-ray
technique that increases clarity and decreases radiation exposure.
concentric contraction Muscle contraction in which tension in the
muscle is greater than the external load on the muscle, resulting in
muscle shortening.
COX-1 and COX-2 See cyclooxygenase systems.
CT scan See computerized tomography.
cubital tunnel syndrome Results from injury, compression, or traction of the ulnar nerve at the elbow resulting in pain, numbness, and
weakness of the forearm and hand. It is commonly found in RSI.
cumulative trauma disorders (CTDs) One of many synonyms for
RSI.
CVS See computer vision syndrome.
cyclooxygenase systems (COX-1 and COX-2) Enzymes found in tissues that have homeostatic functions (COX-1) and result from inammation in tissues (COX-2). Inhibition of COX-2 enzymes is desirable,
while inhibition of COX-1 enzymes is not. Certain enzymes affect
either or both of these systems.
deep tendon reexes (DTRs or tendon jerks) The involuntary contractions of muscles after brief stretching, caused by tapping of the
muscles tendons.
Dellons test See two-point discrimination test.
DeQuervains disease A painful inammation due to friction and
tightness of the common tendon sheath of the abductor pollicis longus
muscle and the extensor pollicis brevis muscles at the base of the
thumb.
depression A state of depressed mood characterized by feelings of sadness, despair, and discouragement. Often accompanied by feelings of
low self-esteem, guilt, and eating and sleep disturbances.
218
Glossary
dorsiexion Flexion or bending of a limb toward the extensor surface

(exing upward as in pushing a door).
Double-jointedness See hyperlaxity.
Dupuytrens contracture Flexion deformity of the ngers due to brosis of the palmar fascia (the covering of the palmar hand muscles).
dynamometer Device for measuring force or strength, such as grip or
pinch dynamometers.
EAST (elevated arm stress test) See Roos test.
eccentric contraction This occurs when an already stretched muscle
contracts while in use. Excessive eccentric muscle contraction in an
elongated muscle can be damaging to that muscle.
electroneurography (NVC) A technique used to measure the conduction, velocity, and latency of peripheral nerves. Considered the
gold standard for diagnosing carpal tunnel syndrome.
electromyogram (EMG) A technique used to measure the duration
and intensity of muscle activity. Usually done in conjunction with
electroneurography.
EMG See electromyogram.
epicondyle A normal bump on a bone where tendons are attached to
the bone.
epicondylitis Inammation of the epicondyle and its adjacent tendon.
ergonomics The science of relating man to his work, applying
anatomic, physiologic, and mechanical principles to produce efciency
in the work.
eustress Mental, emotional, or physical stimuli that result in pleasure.
eye dominance The eye that is used predominantly in the visual
process. It does not necessarily correlate to hand dominance.
bromyalgia Characterized by widespread muscle pain not usually
associated with weakness. A number of other symptoms, including
joint pain, headache, and gastrointestinal symptoms, may also be present. Multiple painful trigger points are helpful in making the diagnosis. It occurs predominantly in women.
brosis The replacement of normal tissue by brous scar tissue at the
site of injury.
Finkelsteins test In this test, one makes a st with the thumb underneath the ngers and moves the st in the direction of the fth nger
in ulnar deviation. If there is pain at the base of the thumb, DeQuervains tenosynovitis is present.
Glossary
219
icker The ickering movement of a CRT computer image based on

the refresh or scanning rate of the picture.
foramen A natural opening through bone or soft tissue.
ganglion cyst The most common swelling in the hand, which usually
arises from the tendon sheath and is often found on the dorsum (top)
of the wrist.
gamekeepers thumb See ulnar collateral ligament tear.
golfers elbow See medial epicondylitis.
glucose (dextrose) Sugar in fruits, plants, and in the blood of all animals. Blood glucose is elevated in diabetes mellitus.
grip strength In this test one makes a fist while holding a grip
dynamometer, and the quantity of the force generated is measured.
Guyons canal syndrome (ulnar tunnel syndrome) Ulnar nerve
compression at the wrist occurring in the ulnar tunnel, which is made
up of the pisiform and hamate bones on each side of the nerve and
roofed over by the transverse carpal ligament.
humerus The upper arm bone, which connects above with the scapula
and below with the radius and ulna bones.
hyperlaxity The ability of a joint to move beyond the normal range of
motion of most people. Also called double-jointedness.
intrinsic muscles of the hand A group of muscles that move the ngers and thumb in many directions. They consist of the interossei and
lumbricals as well as the abductor pollicis brevis, opponens pollicis,
exor pollicis brevis, abductor pollicis, adductor pollicis, palmaris brevis, abductor digiti quinti, exor digiti quinti brevis, and opponens
digiti quinti. They mostly act as a group to provide the sophisticated
movement necessary for the hand.
iontophoresis The induction by means of an electric current of ions of
soluble salts and medicines into the tissues as a means of introducing
these medicines into the body.
isometric contraction Muscle contraction in which tension of the
muscle equals the external load on the muscle, resulting in constant
muscle length.
isotonic contraction Muscle contraction in which a constant internal
tension is developed, resulting in a concentric muscle contraction.
lateral epicondylitis (tennis elbow) Inammation of the bony eminence at the elbow from which the wrist extensor muscle tendons
originate.
220
Glossary
ligament A band of brous tissue that connects bones or cartilage and

that supports and strengthens joints.
Linburgs anomalous tendon Fibrous or tendinous bands connecting
the exor pollicis longus and index profundus tendons. An anomaly
that restricts independent thumb exion when the index nger is
extended.
magnetic resonance imaging A noninvasive diagnostic technique
used to image the structure of the body. The patient is placed in the
eld of an electromagnet capable of producing images in a variety of
planes. It is used primarily to evaluate soft tissues. The procedure is
considered to be without risk to the patient except under certain circumstances.
MSDs See musculoskeletal disorders.
mechanical allodynia The result of pressure on soft tissues that produces pain that normally would not occur.
medial epicondylitis (golfers elbow) Inammation of the bony eminence at the elbow from which the wrist exor forearm pronator
groups of muscles originate.
MRI See magnetic resonance imaging.
musculoskeletal disorders (MSDs) A term used to described the
variety of symptoms caused by repetitive motion.
myofascial pain syndrome Muscle pain and soreness often associated
with repetitive motion.
nerve conduction velocity (NCV) See electroneurography.
NSAIDs See nonsteroidal anti-inammatory drugs.
nociceptors Nerve bers responsible for the sensation of pain.
nonsteroidal anti-inammatory drugs (NSAIDs) A group of compounds with similar analgesic and anti-inammatory properties; now
divided into conventional and gastrointestinal protective.
norepinephrine A naturally occurring catecholamine that is a major
neurotransmitter released in response to stress and hypotension (lowered blood pressure).
occupational overuse syndrome (OOS) One of many synonyms for
repetitive strain injury (RSI).
overuse syndrome A synonym for repetitive strain injury usually
applied to musicians injuries.
panic disorder A state of extreme anxiety associated with disorganization of personality and function.
paresthesias Abnormal sensations of tingling and numbness.
Glossary
221
phonophoresis The induction of medication into the tissues using

high-frequency sound waves.
Physioball (Resistaball) An inatable plastic ball that comes in different sizes; useful for stretching and other exercises.
pinch test In this test using a pinch dynamometer, three pinch
strengths are tested. Pulp pinch (like the way one holds a sheet of
paper), key pinch (like one grips a key), and chuck grip (like the grip
on a pencil with thumb below and forenger and middle nger above)
are measured by exerting pressure on the dynamometer.
postural misalignment In RSI, a term used to describe a typical
round-shouldered, head-forward posture that is a key factor in causing
soft tissue nerve traction and compression problems related to pain,
discomfort, and other symptoms. Postural misalignment is also often
associated with scoliosis and lordosis and is the most common nding
in persons with RSI.
pronation Position of the palm downward, as in typing.
pronator teres muscle syndrome Compression of the median nerve
in the forearm as a result of compression by the pronator teres muscle.
proprioception The conduction of sensory nerve signals that indicate
muscle and joint position to the central nervous system.
prostaglandins Potent mediators of a diverse group of physiologic
processes. PGE2 is an important prostaglandin, which increases vascular permeability, increases pain sensitivity, and raises temperature.
NSAIDs and aspirin inhibit prostaglandin activity.
radial deviation Position of the hand in the direction of the radial
bone on the thumb side of the hand. The opposite of ulnar deviation.
radial tunnel syndrome Compression of the radial nerve as it passes
under the tendinous arch of the supinator muscle at the elbow.
radius The bone on the outer or thumb side of the forearm. It articulates above with the humerus and the ulna and below with the ulna
and the wrist bones.
Raynauds syndrome A painful condition affecting the ngers or toes
caused by compromised circulation and provoked by cold. The digits
turn white for lack of blood supply.
reex sympathetic dystrophy (RSD) See complex regional pain syndrome (CRPS).
reex sympathetic dysfunction Overactivity of the involuntary sympathetic nervous system causing temperature and color changes as
well as sweating in the extremities.
222
Glossary
regional arm pain A term used by some to describe the pain associated with RSI.
REM sleep A term used to describe the rapid eye movement phase of
sleep.
Resistaball See Physioball.
Roos test A test done with arms in the air, in the hold up position, to
see how long the position can be sustained without producing pain,
numbness, or color changes in the skin for a three-minute limit. It is
an important clinical test in the diagnosis of thoracic outlet syndrome.
See also EAST test.
rotator cuff A musculotendinous structure of the shoulder joint
formed by the linked bers of the supraspinatus, infraspinatus, teres
minor, and subscapularis muscles giving the shoulder stability, exceptional range of motion, and strength.
satellite cell A mononuclear stem cell found between the muscle ber
and its surrounding basal lamina. When activated it initiates the rst
phase of muscle ber regeneration.
scalene bands Anomalous brous connections between scalene muscles, sometimes resulting in brachial plexus nerve impairment.
scalene muscles Muscles on either side of the neck composed of three
sections that raise the ribs, rotate the neck, and bend and ex the
spine. The anterior and median muscles can squeeze the nerves of the
brachial plexus, causing the more common form of thoracic outlet
syndrome.
Semmes-Weinstein test The application of threadlike bers of varying
thickness to evaluate sensory nerves in the hands.
sodium channel A protein channel in cells; selective for the passage of
sodium ions.
splints A rigid or exible appliance used to immobilize or protect an
injured part of the body.
stress Usually dened as the sum of biologic reactions to mental, emotional, or physical stimuli that tend to disturb the homeostasis of the
body and that may lead to certain disorders.
supination Turning the palm upward.
supinator syndrome See radial tunnel syndrome.
TENS (transcutaneous electrical nerve stimulator) An electrical
device that stimulates nerve bers that travel to the brain and that produces relief of pain.
Glossary
223
tendinitis Inammation of tendons or their attachment to muscle.

tendon A brous cord attached to muscle or bone that conveys the
action of the muscle to the joint.
tendon sheath A tunnel or sheath that guides a tendon around a
curve; analogous to the ring on a shing rod.
tennis elbow See lateral epicondylitis.
tenosynovitis Inammation of the tendon sheath (e.g., DeQuervains
tenosynovitis).
TFCC See triangulate brocartilage complex.
thermography (thermal video camera, computer-assisted thermography) A technique using an infrared camera to photographically
portray body surface temperature.
Tinels sign This test is performed by lightly tapping along the line of
a nerve. If tingling is felt, the test is positive for nerve impairment.
thoracic outlet syndrome (TOS) This is classied as neurogenic (95
percent) and vascular (5 percent). It is basically the result of compression of the brachial plexus nerve trunks or the subclavian artery or
vein. The neurogenic type is quite common in RSI and appears to be
due to soft-tissue compression of the nerves due to poor posture or
anatomic anomalies.
transverse carpal ligament A ligament that functions as a tendon pulley, which is the roof of the carpal and ulnar tunnels. It is surgically
cut in carpal tunnel syndrome to relieve pressure on the carpal tunnel.
triangulate fibrocartilage complex (TFCC) A complex structure
that stabilizes the wrist. A cause of wrist pain when perforated. It is
associated with wrist fractures and other injuries.
trapezius A at, triangular muscle covering the upper and back part of
the neck and shoulders. It is divided into upper and lower portions.
They rotate the scapula. The upper portion, alone, moves the scapula
upward and braces the shoulder. The lower part, alone, drives the
scapula downward.
trigger nger A tendon entrapment involving the ngers or thumb.
More common in women and characterized by locking of a nodule in
the nger pulley associated with pain on exion.
two-point discrimination test A test used to predict functional nerve
recovery. Two blunt points (a paperclip is typically used) are moved
along the long axis of the limb or nger. The distance between the two
points is decreased until the two points can no longer be distinguished.
UBE See upper-body ergometer.
224
Glossary
ulna The inner large bone of the forearm opposite the thumb. Above,
it articulates with the humerus and the radius, and below, with the
wrist bones on the side of the fth nger.
ulnar collateral ligament tear (gamekeepers thumb) When torn,
the ulnar collateral ligament causes instability of the thumb. It can
result from falling with an outstretched hand or tight gripping and
twisting.
ulnar deviation Position of the hand in the direction of the ulna bone.
A common malpositioning in typists and pianists.
ulnar tunnel syndrome See Guyons canal syndrome.
upper-body ergometer (UBE) An upper-body exercise device useful
for increasing shoulder and arm range of motion and strength.
vertebra One of thirty-three bones of the spinal column, including the
cervical, thoracic, lumbar, sacral, and coccygeal sections.
Wartenbergs syndrome An isolated neuritis of the supercial branch
of the radial nerve at the wrist, especially caused by external compression such as wearing a splint or a tight watchband.
Wrights test A one-minute test where arms are raised and held
against the ears to evaluate compression and traction of the brachial
plexus in thoracic outlet.
Further Reading
Introduction
Reid, J., C. Ewan, and E. Loy. 1991. Pilgrimage of pain: The illness experiences of women with repetitive strain injury and the search for credibility.
Social Science Medicine 32:601612.
Stevens, J. C., J. C. Witt, E. S. Benn, and A. L. Weaver. 2001. The frequency of carpal tunnel syndrome in computer users at a medical facility.
Neurology 56:15681570.
U.S. Department of Labor. 1999. Occupational Safety and Health Administration, 29 CFR part 1910. Ergonomics program, proposed rule, part 22.
November 23.
Chapter 1: Understanding RSI

Groopman, J. 2000. Hurting all over: With so many people in so much pain
how could bromyalgia not be a disease? The New Yorker, November 13.
Mackinnon, S. E., and C. B. Novak. 1997. Repetitive strain in the workplace. Journal of Hand Surgery 22 (1): 218.
Magee, D. J. 1987. Orthopedic Physical Assessment. New York: W. B. Saunders.
Pascarelli, E. F., and Y. P. Hsu. 2001. Understanding work-related upper
extremity disorders: Clinical ndings in 485 computer users, musicians,
and others. Journal of Occupational Rehabilitation 11 (1): 121.
Chapter 2: Getting the Diagnosis

Beasley, R., N. Raymond, S. Hill, M. Nowitz, and R. Hughes. 2003. Venous
thromboembolism in a computer user. European Respiratory Journal 21:
374376.
225
226
Further Reading
Brooke, James. 2002. Youth let their thumbs do the talking in Japan. New
York Times, May 9.
Gordon, S. L., S. J. Blair, and L. F. Fine, eds. 1995. Repetitive Motion Disorders
of the Upper Extremity. Rosemont, Ill.: American Academy of Orthopedic
Surgeons.
Machleder, H. I. 1998. Neurogenic thoracic outlet compression syndrome.
In Vascular Disorders of the Upper Extremity, 3rd ed., ed. H. I. Machleder,
131135. Mount Kisco, N.Y.: Futura.
Millender, L. H., ed. 1992. Occupational Disorders of the Upper Extremity. Livingstone, N.Y.: Churchill.
Pcina, M. M., J. Krmpotic-Nemanic, and A. D. Markiewitz. 1991. Tunnel
Syndromes. Boca Raton, Fla.: CRC Press.
Roos, D. B. 1976. Congenital anomalies associated with thoracic outlet syndrome: Anatomy, symptoms, diagnosis, and treatment. American Journal
of Surgery 132 (6): 771778.
. 1990. The thoracic outlet syndrome is underrated. Archives of Neurology 47 (3): 327328.
Silverstein, B. A., D. S. Stetson, W. M. Keyserling, and L. J. Fine. 1997.
Work-related musculoskeletal disorders: Comparison of data sources for
surveillance. American Journal of Industrial Medicine 31 (5): 600608.
Sjogaard, G, and B. R. Jensen. 1996. Muscle pathology with overuse.
Chronic Upper Limb Musculo-Skeletal Injuries in the Workplace, ed. D. Ranney. Philadelphia: W. B. Saunders.
Sucher, B. M., and D. M. Heath. 1993. Thoracic outlet syndromea
myofascial variant. Part 3: Structural and postural considerations. Journal
of the American Osteopathic Association 93 (3): 334, 340345.
Chapter 3: RSI and Your Emotions

Charney, D. S., and A. Deutch. 1996. A functional neuroanatomy of anxiety and fear: Implications for the pathophysiology and treatment of anxiety disorders. Critical Review of Neurobiology 10 (34): 419446.
Friedman, T. L. 2000. Cyberserfdom. New York Times, July 30.
Raskin, N. H., M. W. Howard, and W. K. Ehrenfeld. 1985. Headache as
the leading symptom of the thoracic outlet syndrome. Headache 25 (4):
208210.
Reid, J., C. Ewan, and E. Lowy. 1991. Pilgrimage of pain: The illness experiences of women with repetitive strain injury and the search for credibility. Social Science Medicine 32: 601612.
Sheon, R. P. 1997. Repetitive strain injury: An overview of the problem and
the patients: The Gulf Group. Postgraduate Med 102 (4) 5356, 6268.
Further Reading
227
Tarkan, L. 2000. Athletes injuries go beyond the physical. New York Times,
September 26.
Tenner, E. 1996. Why Things Bite Back: Technology and the Revenge of Unintended Consequences. New York: Alfred A. Knopf.
Chapter 4: RSI and Your Eyes

Leavitt, S. B. 1995. Vision Comfort at VDTs. Glenview, Ill.: Leavitt Medical
Communications.
Chapter 5: Managing Pain

Bombardier, C., L. Laine, A. Reicin, D. Shapiro, R. Burgos-Vargas, B.
Davis, R. Day, et al. 2000. Comparison of upper gastrointestinal toxicity
of rofecoxib and naproxen in patients with rheumatoid arthritis: VIGOR
Study Group. New England Journal of Medicine 343 (21): 15201528.
FitzGerald, G. A., and C. Patrono. 2001. The coxibs, selective inhibitors of
cyclooxygenase-2. New England Journal of Medicine 345(6):433442.
Hooshman, H. 1993. Chronic pain. In Reflex Sympathetic Dystrophy Prevention
and Management, 202. Boca Raton, Fla.: CRC Press.
Pittman, D. M., and M. J. Belgrade. 1997. Complex regional pain syndrome. American Family Physician 56 (9): 22652270, 22752276.
Victor, M., A. H. Ropper, R. D. Adams, and M. Victor. 2000. Adams and
Victors Principles of Neurology, 7th ed. New York: McGraw-Hill.
Chapter 6: Your Lower Back

Tulder, M., and B. W. van Koes. 2001. Low back pain and sciatica. Clinical
Evidence 5:772789.
Frymoyer, J. W. 1988. Back pain and sciatica. New England Journal of Medicine 318 (5): 291300.
Snook, S. H., R. A. Campanelli, and J. W. Hart. 1978. A study of three preventive approaches to low back injury. Journal of Occupational Medicine 20
(7): 478481.
Chapter 7: Physical and Occupational Therapy for RSI

Jordan, S. E., S. S. Ahn, J. A. Freisclag, H. A. Gelabert, and H. I. Machleder.
2000. Selective botulin chemodenervation of the scalene muscles for
treatment of neurogenic thoracic outlet syndrome. Annals of Vascular
Surgery 14 (4): 365369.
Novak, C. B. 1996. Conservative management of thoracic outlet syndrome.
Seminars in Thoracic and Cardiovascular Surgery 8 (2): 201207.
228
Further Reading
Chapter 8: Ergonomics: Making Your Equipment Fit

Armstrong, T. J., L. J. Fine, S. A. Goldstein, Y. R. Lifshitz, and B. A. Silverstein. 1987. Ergonomics considerations in hand and wrist tendinitis. Journal of Hand Surgery 12 (5, pt. 2): 830837.
Bommarito, P. F., M. R. Sandberg, and G. D. Shurts. 2001. Survey of laptop computers at Lawrence Livermore National Laboratory. Washington, D.C.: U.S. Department of Energy, UCRL-AR-146102.
Bruce, O., C. Dickerson, and C. Zenz, eds. 1994. Occupational Medicine, 3rd
ed. St. Louis: C. V. Mosby.
Kay, M. 2003. Type It Anywhere. Scientific American, January, 3233.
Kroemer, K. H. E., and E. Grandjean. 1997. Fitting the Task to the Human: A
Textbook of Occupational Ergonomics, 5th ed. London: Taylor & Francis.
Tenner, E. 1997. How the chair conquered the world. Wilson Quarterly
Spring: 6470.
Peper, E., and K. H. Gibney. 1997. Computer solutions to computer pain:
How to stay healthy at the computer with e-mail tips BMVG. Berkely
Peachpit Press Newsletter 13 (2): 174175.
Chapter 9: Biomechanics: Using Your Body

Pascarelli, E. F. 1999. Training and retraining of ofce workers and musicians. Occupational Medicine 14 (1): iv, 163172.
Pascarelli, E., and J. Kella. 1993. Soft-tissue injuries related to use of the
computer keyboard: A clinical study of 53 severely injured persons. Journal of Occupational Medicine 35 (5): 522532.
Chapter 10: At Home with RSI

The information in this chapter is from personal communications with Lisa
Sattler, P.T., Vera Wills, and Yu-Pin Hsu, O.T.
Chapter 11: Getting Back to Work

Kanigel, R. 1996. Frederick Taylors apprenticeship. Wilson Quarterly Summer: 4451.
Morse, T., C. Dillon, and N. Warren. 2000. Reporting of work-related musculoskeletal disorder (MSD) to workers compensation, 281292. Amityville, N.Y.: New Solutions, Baywood Publishing.
Thompson, N. 2002. Make Mine DVORAK: One writers love affair with
the other keyboard layout. February 5. http://www.slate.msn.com/
toolbar.aspx?action=print&id=2061547.
Further Reading
229
Chapter 12: RSI and Musicians

Diagram Group. 1976. Musical Instruments of the World: An Illustrated Encyclopedia. New York: Paddington Press.
Graffman, G. 1986. Doctor, can you lend an ear? Medical Problems of Performing Artists 1: 13.
Hsu, Yu-Pin. 1997. An analysis of contributing factors to repetitive strain
injury (RSI) among pianists, 481506. Ann Arbor, Mich.: UMI Dissertation Service.
Lederman, R. J. 1986. Thoracic Outlet Syndrome: Review of the controversies and a report of 17 instrumental musicians. Medical Problems of Performing Artists 2: 87.
Newmark, J., and F. H. Hochberg. 1987. Isolated painless manual incoordination in 57 musicians. Journal of Neurology and Neurosurgical Psychiatry 50
(3): 291295.
Chapter 13: Other Causes of RSI

Feuerstein, M., and T. E. Fitzgerald. 1992. Biomechanical factors affecting
upper extremity cumulative trauma disorders in sign language interpreters. Journal of Occupational Medicine 34 (3): 257264.
Punnett, L., J. M. Robins, D. H. Wegman, and W. M. Keyserling. 1985.
Soft-tissue disorders in the upper limbs of female garment workers. Scandinavian Journal of Work and Environmental Health 11 (6): 417425.
Spurgeon, A., J. M. Harrington, and C. L. Cooper. 1997. Health and safety
problems associated with long working hours: A review of the current
position. Occupational and Environmental Medicine 54 (6): 367375.
Chapter 14: Beating RSI: A Five-Step Protection Plan

Bernacki, E. J., and S. P. Tsai. 1996. Managed care for workers compensation: Three years of experience in an employee choice state. Journal of
Occupational and Environmental Medicine 38 (11): 10911097.
Bernard, B. P., ed. 1997. Musculoskeletal Disorders and Workplace Factors: A
Critical Review of Epidemiologic Evidence for Work-Related Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back. Washington, D.C.: U.S.
Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health.
Leigh, J. P., S. B. Markowitz, M. Fahs, C. Shin, and P. J. Landrigan. 1997.
Occupational injury and illness in the United States: Estimates of costs,
morbidity, and mortality. Archives of Internal Medicine 157 (14): 15571568.
Internet Resources
Typing Injury FAQ

http://www.tifaq.org/organizations
A list of a wide range of governmental and private organizations related to
RSI. Includes documents from the technical literature, plus useful advice in
nontechnical form. This a good primary source for nding relevant Web
sites.
National Coalition on Ergonomics

http://www.ncergo.org
An organization of associations and businesses interested in sound ergonomics.
Ofce of Ergonomic Research Committee
http://www.oerc.org
An association of companies devoted to research in ergonomics.
Human Factors and Ergonomics Society
http://hfes.org/
An advocacy organization promoting knowledge and exchange of ideas
about ergonomics and the use of such knowledge in designing systems to
ensure effectiveness, safety, and ease of use.
231
232
Internet Resources
Coalition of New Ofce Technology

http://www.ctdrn.org/cnot
An organization focusing on ofce technology, particularly emphasizing
women workers.
Association of Repetitive Motion Syndromes (ARMS)
http://www.certiedpst.com/arms/
A nonprot charity that works as a national clearinghouse for support and
information to at-risk workers, their employers, workers compensation
professionals, the press, and the public concerning preventive, therapeutic,
medical, and legal aspects of repetitive motion syndromes.
Information about Treatment and RSI Educational Materials
http://www.lisasattler.com
CTD Resource Network, Inc.
http://www.ctdrn.org
CTDRN brings together existing, online educational publications and provides a vehicle to more directly assist those suffering from, or at risk of,
cumulative trauma disorders.
University of Michigan Rehabilitation Engineering
Research Center
http://umrerc.engin.umich.edu/jobdatabase/default.asp
The overall goal of the RERC is to prevent disability associated with musculoskeletal disorders and aging.
General Scientic
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Index
abdominal exercises, 124

accommodation, 7980
acetaminophen, 99
acupressure, 9394
acupuncture, 9394
Addison, Joseph, 183
Advil, 98
age-related macular degeneration,
8586
Alexander, F. M., 128
Alexander technique, 128
American Academy of Orthopedic
Surgeons, 159, 160
American College of Rheumatology, 60
American Psychiatric Association,
71
amitryptyline, 100
anaphylactoid reaction, 98
anatomy, 1020
anomalies or quirks, 1819
destiny and, 1920
elbow, 1415
forearm, 1415
ligaments, 18
muscles, 17
nerves, 17
shoulder, 1314
skeletal system, 1112
spinal column, 1213
tendons, 1718
wrist, 1517
anterior interosseous syndrome, 36
antidepressants, 100101
anti-inammatory medications,
9699
anxiety disorders, 7073
Armstrong, Thomas, 139
Arthrotec, 98
aspirin, 98, 99
Aventyl, 100
backpacks, 152
kids and, 159160
back schools, 109
back to work, 171181
case study, 177178
computer problems, 180
239
240
Index
back to work (continued )

functional capacity evaluation,
180181
injury prevention programs and,
173174
limiting criteria, 178179
readiness for, 178179
rehabilitation and, 175
retraining and, 175176
workers compensation and,
174175
Barrett, Sir William, vii
basic 5 exercises, 121123
bassoon, 199
bathroom problems, 169
beating RSI, 209214
ergonomics, 212213
examining your life, 209210
physical evaluation, 210211
plan prevention and cure,
211212
working the health care system,
213214
Bentham, Jeremy, 87
bicipital tendinitis, 22, 58
bicycle warm-up, 117
bifocals, 82
binocularity, 80
biofeedback, 4041
biomechanics, 149161
computers and. See computers
and biomechanics
as a dynamic process, 150151
ergonomics and, 149
kids and, 159160
personal characteristics and, 150
posture, 151152, 160
training and retraining, 150
video evaluation of, 150151,

161
workstation, 151158
yips in golfers, 161
blood tests, 4445
Blue Cross/Blue Shield of California, 174
Bodyblade, 116
bone densitometry, 41
bone scan, 41
Brubeck, Dave, 194
Bush, George W., 148
Canesta Keyboard Perception
Chipset, 140
capsaicin, 93
carbamazepine, 102
Carbetrol, 102
Carlyle, Thomas, 171
carpal tunnel syndrome (CTS), 5,
15, 17, 42, 95, 117
described, 2223, 5354
testing for, 3536
windshield wiper wrists and,
154155
carrying angle, 37
Cataam, 98
Catapres, 102
cataracts, 85
cathode tube (CRT) computer
screens, 78, 144
causalgia, 90
Celebrex, 98
celecoxib, 98
Celexa, 101
cello, 192
cellular phones, 165
cervical brachial pain syndrome, 4
Index
cervical nerve root compression,

5556
cervical radiculopathy, 3940, 118
chairs, 133134
armrests, 133134
easy adjustability, 134
footrests, 134
high-backed, 133
kneeling chairs, 134
standing vs., 134
Chan, Jacqueline, 203
children, 159160
choline magnesium trisalicylate, 99
chondroitin sulfate, 103104
choosing a physician, 2728
citalopram, 101
clacking, 159
clarinet, 198
clinical nerve testing, 40
Clinical Skills Assessment Examination (CSAE), 34
clonidine, 102
codeine, 99, 103
computer input devices, 141143
mouse, 141142
other, 143
touch pad, 143
track ball, 142
computerized tomography (CT
scan), 41, 90
computer keyboards, 136140
adjustable, 138
biomechanics and. See computers
and biomechanics
xed-split, 137138
history of, 171173
hot keys, 139
laptop, 140
241
nail length and, 157

touch and tactile feedback, 139
traditional, 137
virtual, 140
wrist rests, 139140
computers and biomechanics,
152158
carrying angle at the elbow,
155156
clacking, 159
dorsiexion, 152154
nger hyperextension, 156157
nger hyperexion, 157
kids and, 160
kneading, 158
mouse use, 159
returning to work and, 180
thumb hyperextension, 158
thumb hyperexion, 158
ulnar and radial deviation,
154155
computers and ergonomics
changing workstations, 145146
document holders, 144
equipment checklist, 146147
input devices. See computer input
devices
keyboards. See computer keyboards
kids and, 160
LCD projectors, 145
monitors, 144145
voice-activated software, 145
Computers in the Schools, 160
computer vision syndrome (CVS),
7881
contact lenses, 82
continuum lens, 82
242
Index
Cornell University, 160

corticosteroids, 94
court stenographers, 201203
cubital tunnel syndrome, 15, 42
described, 22, 5152
cumulative trauma disorders
(CTDs), 3
cyclooxygenase systems (COX),
9798, 99
Darvocet, 103
Darvon-N, 103
day-to-day tasks, 163170
in the bathroom, 169
domestic help, 165
driving, 169170
hand and nger movements,
168
in the kitchen, 168169
living alone, 164165
overview, 163164
reading, 167168
relaxation, 167
sexual activity, 167
sharing chores, 164
sleeping, 166167
telephone, 165166
dental professionals, 204205
depression, 7375
antidepression drugs, 100101
DeQuervains tenosynovitis,
2425, 35, 57, 63, 95, 154
desipramine, 100
desks, 135136
pullout trays, 135136
diagnosis, 2768.
examination. See physical
examination
making the correct, 6465

pain pictogram, 29, 33
patient questionnaire, 3032
questions that need answers, 28
specialists and, 2728
tests. See specic tests
visiting the doctor, 2829
diagnostic and lab tests, 40
diclofenac, 98
distress, 70
document holders, 144
domestic help, 165
dorsiexion, 152154
double bass, 192
double-jointedness, 1819, 61
driving problems, 169170
drugs. See medications
dynamometer, 35, 36
Economy Class Syndrome,
6364
elbow, 1415
carrying angle, 155156
examination of, 37
electrocardiography (ECG), 41
electromyography, 35, 37
electroneurography, 42
Elevated Arm Stress Test (EAST),
38
emotions, 6975
anxiety disorders, 7073
depression, 7375
overview, 6970
stress, 70
ergonomics and beating RSI,
212213
ergonomics of musical instruments,
186188
Index
ergonomic workstations, 131148

biomechanics and, 149
chairs, 133134
computers. See computers and
ergonomics
desks, 135136
equipment checklist, 146147
overview, 132
pens and pencils, 143144
standards for, 148
stress and, 146
tips for, 8384
vision and, 8283
eustress, 70
examining your life, 209210
exercise program, 113127
Bodyblade, 116
musicians and, 188
need for, 113114
running and walking, 117
stationary bicycle, 117
strengthening. See strengthening
exercises
stretches, 117120
upper body ergometer, 115116
wall angels, 114115
warm-ups, 114120
extensor muscles, 153
eye dominance, 8081
eyes, 7786
checkups, 7778
computer vision syndrome,
7881
problems related to, 78, 8486
visual tools, 8184
Federation of State Medical Boards
(FSMB), 34
243
Feldenkrais, Moshe, 128

Feldenkrais method, 128
bromyalgia, 60
nger hyperextension, 156157
nger hyperexion, 157
Finkelsteins test, 35
exor muscles, 153
uoxetine HCL, 101
focal dystonia, 42, 161
in musicians, 196198
Fontaine, Jean de la, 111
forearm, 1415
examination of, 36
French horn, 19899
Fry, H. J. H., 198
functional capacity evaluation,
180181
gabapentin, 90, 91, 101102
ganglions, 61
garment workers, 203204
generalized anxiety disorder
(GAD), 72
Gibbs, W. Wayne, 145
glaucoma, 85
glucosamine, 103104
Goldberg, Robert, 205
golfers elbow, 23, 56
Grandjean, tienne, 83, 131
guitar, 193
Guyons canal syndrome, 52
hand intrinsic exercises with putty,
126
hands, examination of, 35
handwriting, 168
Hansen, Malling, 171
harp, 190
244
Index
harpsichord, 188190
Harrison, Robert, 203204
health care system, 174175,
213214
heat treatment, 93
Hedge, Alan, 138
Heller, Joseph, 129
Hellerwork, 129
Hello Direct Catalog, 165
herniated discs, 55
heterophoria, 80
hold-up exercise, 122
home exercises, 104
Horowitz, Vladimir, 187
housekeepers, 165
Hsu, Yu-Pin, 188, 189
hyperlaxity, 1819, 61
ibuprofen, 98
icing, 9293
Inderal, 102103
inferior trunk injury, 4849
infrared camera analysis, 42
injury prevention programs, 174
International Association for the
Study of Pain, 90
International Congress of
Symphony and Orchestra
Musicians (ICSOM), 200
Internet resources, 231232
interossei muscles, 156, 157
iontophoresis, 94
Jung, Carl, 69
Kawai, 187
keyboard instruments, 186190
keyboard layouts, 171173
kitchen problems, 168169

kneading, 158
Lancet, 141
laptop computers, 140141
lateral cord injury, 49
lateral epicondylitis, 2324, 56, 154
latissimus dorsi pull-downs,
123124
Leavitt, Stuart B., 83
ligaments, 18
injury to, 6061
lighting, 83
limbic system, 88
Linburgs tendon, 35, 62
liquid crystal display (LCD)
computer screens, 78, 82, 85, 144
projectors, 145
L. L. Bean, 174
Locke, John, 9
Los Angeles Times, 174
lower back pain, 105110
acute, 108109
causes of, 107108
chronic, 109
dening, 106108
incidence of, 106
posture and, 105, 106
risk factors, 106
surgery for, 109110
treatment of, 108109
lumbrical muscles, 156, 157
Magnetic Resonance Imaging
(MRI), 43
manual therapy, 127
Maximilian Violin, 187, 191
mechanical allodynia, 38, 39
Index
mechanical typewriter, 171173

medial cord injury, 48
medial epicondyle, 23, 56
median nerve, 15
injury to, 5254
medical history, 29
medications. See also specic
medications
acute pain, 96104
anxiety and, 71
GAD, 72
panic disorder, 73
PTSD, 73
sleep, 166167
migraine headaches, 48
Milton, John, 105
misoprostol, 98
Morello, Joe, 194
mouse, computer, 141142
incorrect use of, 159
Moynihan, Daniel Patrick, 84
multitasking, 84
muscle relaxants, 99100
muscles, 17
controlling nger movements,
156157
injury to, 5860
testing of, 40
Musculoskeletal Disorders and
the Workplace, 173
musicians, 150, 183200
cello, 192
double bass, 192
ergonomics and, 186188
exercise and, 188
ute, 194196
guitar, 193
harp, 190
245
keyboard instruments, 186190,

197198
orchestra problems, 199200
overview, 183184
percussion, 193194, 199
reeds, 198
statistics on injuries to, 184186
viola, 189, 191
violin, 187, 190191, 196
wind instruments, 187, 198199
myofascial pain syndrome, 25
myofascial release, 127
nabumetone, 98
Nakama, Yoshimo, 186
National Academy of Sciences,
173
National Association of the Deaf
(NAD), 206
National Board of Medical Examiners (NBME), 34
neck examination, 38
nerve compression, 1213
nerve conduction velocity (NCV),
42
nerves, 17
neurogenic thoracic outlet
syndrome. See thoracic outlet
syndrome (TOS)
Neurontin, 90, 91, 101102
New York Times, The, 57n, 173, 174
noise attenuators, 200
nonsteroidal anti-inammatory
medications (NSAIDs), 9699
conventional, 97
COX systems and, 9798
gastroprotective, 98
Norex, 100
246
Index
Norpramin, 100
nortriptyline HCL, 100
Oates, Shawn, 160
oboe, 198
occupational medicine, 171
occupational overuse syndrome
(OOS), 4
Occupational Safety and Health
Administration (OSHA), 148,
173
occupational therapy. See therapy
for RSI
opioid-based medications, 103
orchestra problems, 199200
organ, 18890
orphenadrine citrate, 100
Osler, William Henry, 27
overuse syndrome, 4
Oxo Company, 169
oxycodone, 103
Oxycontin, 103
pain, 87104
acupressure for, 9394
acupuncture for, 9394
acute, 88
anesthetics for, 94
chronic, 88
complex chronic, 8889
corticosteroids for, 94
drug treatment of, 96104
heat for, 93
icing for, 9293
iontophoresis for, 94
lower back. See lower back pain
phonophoresis for, 94
progression of RSI and, 8788
rest and, 92
RSD/CRPS and, 8992
self-treatment of, 9293
splints for, 9596
TENS for, 93
pain pictogram, 29, 33
panic disorder, 73
paroxetine HCL, 101
patient questionnaire, 3032
Paxil, 101
Payne, J. H., 163
Pellagrina Viola, 187, 191
pens and pencils, 143144
percussion instruments, 193194,
199
personal computer, 173
personal trainers, 113
Phelans test, 35
phonophoresis, 94
physical examination, 3345
beating RSI and, 210211
clinical skills of the physician
and, 34
elbows, 37
forearms, 36
hands, 35
neck, 38
posture, 38
shoulders, 37
tests. See specic tests
wrists, 3536
physical therapy. See therapy for
RSI
physioball/resist-a-ball exercises,
119
piano, 188190
focal dystonia and, 197198
special keyboards for, 186187
Index
piccolo, 196
Pilgrimage of Pain, 2
plasma monitors, 78, 82, 85
plethysmography, 43
Positive Emission Tomography
(PET scan), 43
posterior cord injury, 49
post-traumatic stress disorder
(PTSD), 7273
posture
bipedal, 106
examination of, 38
lower back pain and, 105
misalignment of, 4647
poor, 2021, 92
workstation biomechanics and,
151152
Principles of Scientic Management
(Taylor), 173
Procrustes, 186
proles of injury, 4564
ganglions, 61
how RSI begins, 4546
ligaments, 6061
Linburgs tendon anomaly, 62
median nerves, 5254
muscles, 5860
neurogenic thoracic outlet
syndrome, 4752
other, 6264
postural misalignment, 4647
radial nerves, 5456
tendons, 5658
progressive lenses, 82
pronator exercise, 125
pronator teres muscle syndrome,
15, 36
described, 5253
247
prone scapula retraction exercise,

122
Propacet, 103
propanolol, 102103, 200
propoxyphene napsylate, 103
proprioception, 18
protruding scapulas, 38
Prozac, 101
punching the ceiling exercise, 121
radial deviation, 154155
radial nerve, 15
injury to, 5456
radial tunnel syndrome, 15
described, 5455
radiculopathy, 1213
Radio Shack, 165
Ramazzini, Bernardino, 1, 171
reading problems, 16768
reeds, 198
reex sympathetic dysfunction,
2122, 50, 88
reex sympathetic dystrophy/complex regional pain syndrome
(RSD/CRPS), 17, 22, 42
diagnosis of, 5051, 9091
pain and, 8990
stages of, 50
treatment of, 9192
type 1 and type 2, 90
regional arm pain, 4, 5
Registry of Interpreters for the
Deaf (RID), 206
Relafen, 98
relaxation, 167
Remington Arms Company, 171
Rempel, David, 139
repetitive motion disorders, 34
248
Index
repetitive strain injury (RSI)

accusations against victims of, 2,
107
anatomy and. See anatomy
beating. See beating RSI
causes of, 4, 10
conservative treatment of, 3, 5
court stenographers and,
201203
dental professionals and,
204205
described, 3
garment workers and, 203204
at home. See day-to-day tasks
kids and, 159160
musicians and. See musicians
other names for, 34
physical exam to diagnose, 10,
2025
prevention of, 173174
proles of. See proles of injury
sign language interpreters and,
206207
symptoms of, 1, 9, 20
therapy for. See therapy for RSI
what it is not, 56
workers compensation and,
174175
resistant tennis elbow, 2324,
5455
rest, 92
returning to work. See back to
work
Riemann, Hannah, 186187
Rivinus, David Lloyd, 187
rofecoxib, 98
Rolf, Ida P., 128
Rolng, 128129
Roos test, 38
described, 39
Rostropovich, Mstislav, 192
running, 117
Satchmo syndrome, 199
Sattler, Lisa, 164
scalene bands, 19
scalene muscles, 47, 48
stretches for, 118
Schumann, Robert, 196
Schwartzman, Robert J., 50
Scientic American, 140, 145
scientic management, 173
scintiscan, 41
scoliosis, 38
screen lenses, 82
selective serotonin reuptake
inhibitors (SSRIs), 100, 101
Semmes-Weinstein monolament
test, 40
sertraline HCL, 101
sexual activity, 167
Sheedy, James, 78
Sholes and Glidden, 171, 172
shoulder, 1314
described, 5758
examination of, 37
loss of range of motion in, 22
shoulder abduction exercise, 122
shoulder shrugs, 126
side-lying external rotation exercise, 122
side-lying whole arm raises exercise, 121
sign language interpreters, 206207
skeletal system, 1112
sleeping problems, 166167
Index
slipped disc, 1213

soft tissue work, 127
sound control, 200
specialists, medical, 2728
spinal column, 1213
splints, 9596
spondylolisthesis, 106
spondylolysis, 106
Spurlings test, 56
stage fright, 200
Staples, 165
static loading, 105
Steinway, 187
stellate ganglion block, 9091
stenograph machines, 201203
steroids, 94
strengthening exercises, 120127
abdominal, 124
advanced, 123126
basic 5, 121123
hand intrinsics with putty, 126
latissimus dorsi pull-downs,
123124
overview, 120121
prone scapula retraction, 122
punching the ceiling, 121
shoulder abduction, 122123
shoulder shrugs, 126
side-lying external rotation, 122
side-lying whole arm raises, 121
supinator/pronator, 125
wall push-ups, 124
wrist curls, 125
stress, 70
ergonomics and, 146
stretches, 117120
other, 120
physioball/resist-a-ball, 119
249
scalene, 118
trapezius, 118
wrist extensor, 119
wrist exor, 118
superior serratus anterior muscle
exercise, 121
superior trunk injury, 48
supinator exercise, 125
supinator syndrome, 23, 5455
surface electromyography (surface
EMG), 43
sympathetic nerves, 2122, 50, 88
tardy ulnar nerve palsy, 22, 52
Taylor, Frederick Winslow, 173
Tegretol, 102
telephone use, 165166
tendons, 1718
injury to, 5658
tennis elbow, 2324, 56
therapy for RSI, 104, 111129
Alexander technique, 128
certied therapists and, 112
exercise. See exercise program
Feldenkrais method, 128
nding treatment, 112113
Hellerwork, 129
insurance coverage for, 113
overview, 111112
personal trainers, 113
Rolng, 128129
soft-tissue work, 127
yoga, 128
thermography, 4344, 90
thoracic inlet syndrome (TIS), 21
thoracic outlet syndrome (TOS),
13, 19, 42, 161, 188
described, 21, 4752
250
Index
thoracic outlet syndrome (continued )

stretching for, 118
testing for, 38
thrombophlebitis, 6364
thumb hyperextension, 158
thumb hyperexion, 158
Tinels test, 35, 37, 40
tizanidine, 102
Tolstoy, Leo, 149
touch pad, computer, 143
track ball, computer, 142
Transcutaneous Electrical Nerve
Stimulator (TENS), 93
transverse carpal ligament, 23
trapezius stretches, 118
Travell, Janet, 60
triangular brocartilaginous
complex (TFCC), 62
tricyclics, 100101
Trisilate, 99
trumpet, 199
Turri, Pelligrino, 171
ulnar collateral ligament, 6263
ulnar deviation, 15456
ulnar nerve, 1415, 5152
ulnar tunnel syndrome, 17
described, 52
testing for, 36
U.S. Bureau of Labor
Statistics, 6
U.S. Medical Licensing Examination, 34
University of Connecticut, 151
upper body ergometer (UBE),
11516
upper extremity musculoskeletal
disorder (UEMSD), 4
vertebrae, 12
V exercises, 122123
vibrometry, 44
videotape, 150151, 161
viola, 187, 191
violin, 187, 190191, 196
VIOXX, 98
Visiting Nurses Association,
165
voice-activated software, 145
Voltaren, 98
walking, 117
wall angels, 114115
wall push-ups, 124
Wall Street Journal, 161, 186
warm-up exercises, 114116
general body, 117120
Wartenburgs syndrome, 63
weight training
advanced, 12326
basic 5, 121123
overview, 120121
premature use of, 112
Wills, Vera, 164, 168, 195
wind instruments, 187, 198199
windshield wiper wrists,
154155
Wordsworth, William, 201
workers compensation system,
174175, 213214
work-related musculoskeletal
disorder (WRMSD), 4
Wrights test, 38
described, 3940
wrist, 1517
curls, 125
dorsiexion, 152154
Index
wrist (continued )
examination of, 35136
extensor stretches, 119
exor stretches, 118
ulnar and radial deviation,
154155
writers cramp, 42, 161
in musicians, 196198
writing problems, 168
X-rays, 44
Yamaha, 187
yips in golfers, 161
yoga, 128
Zanaex, 102
Zenz, Carl, 131
Zola, mile, 77
Zoloft, 101
251

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Dr.

Emil Pascarelli, M.D.

John Wiley & Sons, Inc.

Emil Pascarelli, M.D.

John Wiley & Sons, Inc.

This book is printed on acid-free paper.

To my wife, Dolores Klein Pascarelli, my daughter,

It is the familiar that usually eludes us in life.

2. Getting the Diagnosis

3. RSI and Your Emotions

4. RSI and Your Eyes

6. Your Lower Back

7. Physical and Occupational Therapy

8. Ergonomics: Making Your Equipment Fit

9. Biomechanics: Using Your Body

10. At Home with RSI

11. Getting Back to Work

12. RSI and Musicians

13. Other Causes of RSI

14. Beating RSI: A Five-Step Protection Plan

General Scientic References on RSI

When Dr. Emil Pascarelli founded the Miller Health Care

Each year we learn more about how to diagnose and manage

ideas and support. My longtime colleague Martin Cherniack,

Medicine, like law, should make a contribution to the

You may have experienced discomfort or pain in your hands,

Dr. Pascarellis Complete Guide to Repetitive Strain Injury

RSI is a general term used to describe a disorder in which

RSI by Other Names

Dr. Pascarellis Complete Guide to Repetitive Strain Injury

What Causes RSI?

What RSI Isnt

Dr. Pascarellis Complete Guide to Repetitive Strain Injury

And it certainly is not a hysterical reaction of bored, lazy, or

New opinions are always suspected, and usually opposed,

To catch RSI before it becomes a more serious or debilitating

Dr. Pascarellis Complete Guide to Repetitive Strain Injury

Repetitive strain injury is not a diagnosis, but a term used to

The Skeletal System

Figure 1. The skeletal system of the upper

Dr. Pascarellis Complete Guide to Repetitive Strain Injury

(RSD/CRPS), where bones lose calcium. The ravages of time,

The Spinal Column

compression occurs where the nerve exits or enters the spinal

The Shoulder, Back, Neck, and

Dr. Pascarellis Complete Guide to Repetitive Strain Injury

The Forearm and the Elbow

Figure 5. The wrist is a complex structure consisting of an intricate relationship between

Tendons and Ligaments

Dr. Pascarellis Complete Guide to Repetitive Strain Injury

Anomalies or Quirks of the Body

Figure 7. Hyperlaxity, or double-jointedness, in the ngers, makes it more difcult to

Figure 8. Double-jointedness at the elbow in a young woman

Anatomy Is Not Always Destiny

Dr. Pascarellis Complete Guide to Repetitive Strain Injury

When the problem is severe and long-term, some soft tissue

The Most Frequent Symptoms

What Your Examination

Thoracic Outlet Syndrome

Reex Sympathetic Dysfunction

Dr. Pascarellis Complete Guide to Repetitive Strain Injury

Loss of Shoulder Range of Motion

Cubital Tunnel Syndrome

Hand dominance R _ L _ Eye dominance R _ L _

_ No _ Yes

More than one workstation? _ Yes _ No

Injury: On the job _ Date ____

Other _ Date ____